Download Co-Occurring Disorders A primer

Co-Occurring Disorders
A primer
Robert W. Johnson BS, AAP
UAB Community Psychiatry Program
REACT Team and Birmingham City Jail
Diversion Project
Defining Co-Occurring Disorders
• Co-Occurring disorder vs. Dual diagnosis
– Co-Occurring disorder is used because
consumers often have more than two
disorders.
• Co-Occurring disorder typically defined as:
– a) At least one substance disorder plus
– b) At least one major mental disorder (i.e.
Major Depression, Bi-polar mood disorder,
any Psychotic disorder) (Axis I)
Co-Occurring Disorders:
Population Estimates:
• Approximately 10 million people in the U.S. have
co-occurring substance and mental disorders
(SAMHSA, 1997).
– 10 million Americans affected by two illnesses
– 3 million Americans affected by three illnesses
– 1 million Americans affected by four or more illnesses
• When consumers with other mental disorders
are considered, (anxiety disorders, personality
disorders) this number increases dramatically.
Co-Occurring Disorders:
Prevalence
National Co-Morbidity Survey
– 52% of those with alcohol disorders at some point in
their lifetime also had a history of at least one mental
disorder.
– 59% of those with other drug disorders at some point
in their lifetime also had a history of at least one
mental disorder.
– 84% of those that experienced a lifetime of cooccurrence report that their mental illness symptoms
preceded their substance use disorder (Kessler et al,
1994).
Co-Occurring Disorders:
Prevalence
Prevalence of co-occurring disorders is
higher in public service systems.
Mental Health
Substance Abuse
Criminal Justice
Individuals with co-occurring
disorders need to be
thought of as the
expectation not the
exception.
Co-Occurring Disorders:
Risk Factors
• Presence of substance use disorder
quadruples the risk of having a cooccurring mental disorder.
• Presence of a mental disorder triples the
risk of having a co-occurring substance
disorder.
• Persons with any one substance use
disorder have an increased risk for
another substance disorder.
Co-Occurring Disorders:
Relapse Factors
• The most common cause of mental illness
relapse in COD consumers is substance abuse.
Especially when the drug of choice is alcohol,
marijuana, or cocaine.
• The most common cause of substance abuse
relapse in COD consumers is untreated mental
illness (SAMHSA, 1997).
• All mental disorders are consistently more
strongly related to dependence than abuse
(Kessler 1996).
Co-Occurring Disorders:
A self defeating cycle
Substance Abuse
Consumer
With
CODs
Mental Health
Co-Occurring Disorders:
Addressing the Continuum
• Low Psych / Low Substance Abuse
• Low Psych / High Substance Abuse
• High Psych / Low Substance Abuse
• High Psych / High Substance Abuse
Co-Occurring Disorders:
Substance Abuse
High severity
Low
severity
III
IV
Less Severe MH
More Severe MH
More Severe SA
More Severe SA
I
II
Less Severe MH
More Severe MH
Less Severe SA
Less Severe SA
Mental Health
High severity
Co-Occurring Disorders:
Forms of Care
• Sequential – This model of service
delivery for CODs is the traditional one. A
person would receive treatment for their
mental health disorder and then, sometime
later, might receive a referral to another
treatment provider to address their
substance disorder or vice versa.
Co-Occurring Disorders:
Forms of Care continued
• This model is unsuccessful, especially if the
person has serious and active symptoms in one
or both categories of disorder.
• The continuity of care is broken. There is no
mechanism in place to address impairments
associated with co-morbidity (i.e. Social
isolation, impaired vocational capability, poor
relationships, ADLs, quality of life, etc.)
Co-Occurring Disorders:
Forms of Care continued
• Parallel – In a parallel model of
intervention, the person receives treatment
for their mental health disorder from one
provider or treatment setting and receives
treatment for their substance use disorder
from another provider – simultaneously.
Co-Occurring Disorders:
Forms of Care continued
• Burden is placed on the individual to negotiate the two
treatment systems and sometimes reconcile,
inconsistent treatment recommendations.
• In many cases, people are often engaged in treatment
programs simultaneously, with no communication
between service providers.
• Historically, this intervention may have consisted of
someone seeing a psychiatrist for their mental health
while being referred to AA to address their substance
abuse.
Co-Occurring Disorders:
Forms of Care continued
• Parallel treatment is difficult for all but the
highest functioning subgroup of people
with CODs – successful achievement
stemming from long term symptom
stabilization in one category of their
disorders and then addressing the other.
• Being challenged by integrated model of
intervention nationwide.
Co-Occurring Disorders:
Forms of Care continued
• Integrated – In this model, treatment of all of the
person’s disorders are considered
simultaneously, in the same service setting,
developed by and delivered by cross trained
staff (MH and SA).
• Service providers are completely engaged in the
treatment planning for both categories of
disorder. Service is typically delivered by a
multidisciplinary treatment team which includes
mental health and substance abuse
professionals.
Co-Occurring Disorders:
Forms of Care continued
• Difficult to find professionals who have
experience in both mental health and substance
abuse. There is a lack of knowledge stemming
from both mental health and substance abuse in
regard to the other discipline.
• Requires a paradigm shift from both disciplines.
Treatment providers are finding it difficult to
adapt to new modalities of treatment (i.e. Harm
reduction).
Co-Occurring Disorders:
Forms of Care continued
• Historically, treatment provision in substance
abuse, has been 12 step or abstinence based.
NAMI shows that abstinence based modalities
have been ineffective in treating consumers with
CODs.
• Battle for service provision.
– Whose clients are they?
– Who is willing to provide services?
Co-Occurring Disorders:
Bridging the Gap
• Community Action Grant: UAB-CPP Birmingham
• Task Force – Alabama Commissioner of Mental Health &
Mental Retardation
• Development of SCATTC (2002) – Southern Coast
Addiction Technology Transfer Center. Serves Alabama
and Florida. Part of the National ATTC Network with a
Unified Mission of:
– Increase knowledge & skills of addiction treatment practitioners.
– Heighten the awareness, knowledge, and skills of all
professionals who interface with addiction treatment.
– Foster regional and national alliances among practitioners,
researchers, policy makers, funders and consumers.
Co-Occurring Disorders:
Bridging the Gap
• PACT & ACT Teams – Substance Abuse
Specialist position, financially supported by
Alabama Dept. of Mental Health &
Retardation (Addictions).
• The Alabama Council of Community Mental
Health Boards.
• ASADS Conferences: Co-Occurring Tracts
• Criminal Justice and Mental Health Conferences
• Integrated Treatment Substance Study Group
• “Train the Trainers” – Cross training through
SCATTC
Individuals with co-occurring
disorders need to be
thought of as the
expectation not the
exception.
Co-Occurring Disorders
Further Readings & Resources
Integrated Treatment for Dual Disorders: A guide to effective practice. Mueser, Noordsy, Drake, and Fox.
Criminal Justice / Mental Health Consensus Project. www.consensusproject.org
Motivational Interviewing, 2nd Edition: Preparing People for Change. Miller, Rollnick, and Conforti
U.S. Dept of Health and Human Services Substance Abuse & Mental Health Services Administration (SAMHSA) www.samhsa.gov
The National Gains Center (COD and Justice System) www.gainsctr.com
National Alliance for the Mentally Ill (NAMI) www.nami.org
National Addiction Technology Transfer Center Network (ATTC) www.addictioned.org
“Co-Occurring Disorders: A Training Series for Counselors” www.fmhi.usf.edu/cmh/training/ole/ole.html
Southern Coast Addiction Technology Transfer Center (SCATTC)
Joan Leary - SCATTC Project Manager for Alabama
401 Beacon Parkway (UAB Substance Abuse)
Birmingham, AL 35209
(205) 917-3780 Ext. 293 or www.scattc.org
Alabama Alcohol & Drug Abuse Association
P.O. Box 660851
Birmingham, AL 35266-0851
(205) 823-1073 or www.aadaa.org
Dual Diagnosis Recovery Network
1302 Division Street, Suite 100
Nashville, TN 37203
(888) 869-9230 Ext. 208 or www.dualdiagnosis.org