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Roger H. Peters, Ph.D., University of South Florida; [email protected] Co-Occurring Disorders 101 Goals of this Presentation Review: • • • How to access relevant resources Challenges in addressing CODs Core components of COD screening, assessment, and treatment for offenders 2 Resources • • • • • • CSAT TIP #42 and #44 Co-Occurring Disorders Integration and Innovation (CODI) Initiative CMHS National GAINS Center CMHS Toolkit—CODs/IDDT Council of State Governments NIDA 3 Defining “Co-Occurring Disorders” The presence of at least two disorders: A substance abuse or dependence disorder A DSM-IV major mental disorder, usually Major Depression, Bipolar Disorder, or Schizophrenia 4 Serious Mental Disorders Axis I Disorders: • Major Depressive Disorder • Bipolar Disorder • Schizophrenia Axis II (Personality) Disorders: • Antisocial Personality Disorder • Borderline Personality Disorder 5 Other Axis I Mental Disorders • Anxiety Disorders (Panic, ObsessiveCompulsive, Social Phobia) • Eating Disorders (Anorexia, Bulimia) • Adjustment Disorders (with anxiety, or depressed mood) • Sleep Disorders 6 Other Axis II Mental Disorders • • • • • Narcissistic Personality Disorder Dependent Personality Disorder Adjustment Disorder Paranoid Personality Disorder Histrionic Personality Disorder 7 Prevalence of Mental Disorders • 26% of adults experience a diagnosable mental disorder each year (60 million persons) • 6% have serious mental disorders • One third have lifetime history of drug use • Co-occurring disorders common 8 Prevalence of Mental Disorders • 10% of adults have a mood disorder (e.g., major depression) • 3% of adults have Bipolar Disorder • 2% of adults have Alzheimer’s Disease • 1% of adults have Schizophrenia • 33% have lifetime history of drug use 9 (GAINS Center, 2004; Steadman et al., 2009) Co-Occurring Substance Use Disorders 74% of state prisoners with mental problems also have substance abuse or dependence problems (U.S. Department of Justice, 2006) 11 Mental Disorders in Juveniles • 67–70% of juveniles experience mental disorders • Key disorders • Substance use disorder–46% • Conduct disorder–46% • Anxiety disorder – 34% • Mood disorder – 18% 12 Types of Juvenile Disorders by Gender (n=1,437) Overall Males Females Anxiety Disorder 34% 26% 56% Mood Disorder 18% 14% 29% Disruptive Disorder 47% 45% 51% Substance Use Disorder 46% 43% 55% Location of COD Services by Severity of Disorders Substance Use Disorders High Severity Low Severity IV III State hospitals, Substance abuse Jails/prisons, system emergency rooms, etc. I Primary health care settings II Mental health system Mental Health Disorders High Severity 14 Offenders with CODs • Repeatedly cycle through the criminal justice and treatment systems • Experience problems when not taking medications, not in treatment, experiencing mental health symptoms, using alcohol or drugs • Small amounts of alcohol or drugs may trigger recurrence of mental health symptoms • Antisocial beliefs similar to other offenders • More criminal risk factors than other offenders 15 Challenges in Addressing CODs • At risk for relapse • Criminality/criminal thinking • Housing needs • Transportation needs • Family reunification • Greater psychological impairment (e.g., trauma) • Job skills deficits • Educational deficits • Stigma related to criminal history and SA and MH disorders • Scarce prevention and treatment resources 16 Outcomes Related to CODs • More rapid progression from initial use to substance dependence • Poor adherence to medication • Decreased likelihood of treatment completion • Greater rates of hospitalization • More frequent suicidal behavior • Difficulties in social functioning • Shorter time in remission of symptoms • Higher rate of failure on probation 17 Relapse Factors and CODs • The most common cause of mental illness relapse is substance abuse • The most common cause of substance abuse relapse is untreated mental illness • Criminal thinking triggers substance abuse relapse 18 Clinical Considerations • Cognitive impairment • Reduced motivation • Impairment in social functioning (Bellack, 2003) 19 Elements of Cognitive Impairment • Difficulty comprehending or remembering important information (e.g., verbal memory) • Not recognize consequences of behavior (e.g., planning abilities) • Poor judgment • Disorganization • Limited attention span • Not respond well to confrontation 20 Traditional MH Services are not Effective for Offenders with CODs • Unaddressed and ongoing SA interferes with individuals’ ability to follow MH treatment recommendations • Active substance use interferes with effectiveness of MH treatment (i.e., medications, etc.) • MH treatment may not focus on changing substance use and other maladaptive behaviors 21 Traditional SA Services are not Effective for Offenders with CODs • Absence of accurate MH diagnosis prevents effective treatment • Cognitive impairment detracts from understanding and processing information • Confrontational approaches used in SA treatment are not well tolerated • Frustration and dropout may result from requirements of abstinence 22 Traditional Supervision Approach is Ineffective for Offenders with CODs • Large caseloads discourage responsive and individualized approach to CODS • Authoritarian and confrontational approach less effective with CODs • Focus on sanctions vs. problem-solving, use of low revocation thresholds • Inconsistent engagement and monitoring in SA and MH treatment • Absence of specialized COD training 23 Why Screen and Assess for CODs? High prevalence rates of mental disorders in justice settings Persons with undetected mental disorders are likely to cycle back through the criminal justice system Allows for treatment planning and linking to appropriate treatment services 24 Screening for CODs • Routine screening for both sets of disorders • Criminal risk level • Acute MH and SA symptoms: • Suicidal thoughts and behavior • Depression, hallucinations, delusions • Potential for drug/alcohol withdrawal • History of MH treatment including use of meds • Determine need/urgency for referral Challenges in Selecting Screening Instruments • • • • • Proliferation of screening instruments Use of non-standardized instruments Instruments not validated in CJ settings Absence of comparative data Direct to consumer marketing of instruments with poor psychometric properties (e.g., SASSI) 26 Enhancing Accuracy of Screening and Assessment • Maintain high index of suspicion for both disorders • Use non-judgmental approach and motivational interviewing techniques • Gather substance abuse information before mental health information • Supplement self-report with collateral information 27 Assessment Considerations • Substance abuse can mimic all major mental health disorders • Several strategies will help to gauge the potential effects of SA on MH disorders - Use drug testing to verify abstinence - Take a longitudinal history of MH and SA symptom interaction - Compile diagnostic impressions over a period of time - Repeat assessment over time 28 Placement Issues and CODs • Excluding persons with CODs is NOT a viable option • How to determine eligibility for services? • Triage to specialized COD services • Target moderate to high criminal risk levels Unique Needs among Offenders who have CODs • Antisocial beliefs and behaviors • Antisocial peers • Need for structured therapeutic activities, supervision, and monitoring • Interrelated nature of MH/SA disorders • Managing community reentry 30 COD Treatment Targets for Offenders • • • • • • • Mental disorders Substance use disorders Criminal thinking/cognitions Developing prosocial peer supports Educational and vocational skills Family interventions Reentry services 31 What Works? Evidence-Based Practices • • • • • Cognitive-behavioral treatment Motivational enhancement Contingency management Integrated treatment for CODs (IDDT) Medications What Works? Evidence-Based Practices • • • • • Illness self-management Family psychoeducation Assertive Community Treatment (ACT) Supported employment Specialized supervision caseloads Specialized Interventions • • • • Trauma and PTSD Criminal Thinking Juveniles Specialized Community Supervision Teams COD Program Phases Orientation Intensive treatment Relapse prevention/transition 35 Pharmacological Interventions • Medications are routinely and effectively prescribed for individuals with CODs • Medications serve to successfully: - Decrease drug cravings - Reduce reinforcing effects of drugs - Assist in acute withdrawal 36 Pharmacological Interventions • Abuse of illicit drugs and alcohol can impair the action of medications • Toxic effects can occur if alcohol or illicit drugs are used while taking certain medications (e.g., lithium, tricyclic antidepressants, MOI inhibitors) • Medications with addictive potential should be avoided, or used with caution 37 Peer Support Interventions • Traditional 12-step programs have not always meshed well with the needs of individuals with co-occurring disorders • 12-step models such as AA and NA have been adapted for co-occurring disorders • “Double Trouble” and similar groups have been developed throughout the U.S. 38 Key Transition Services • Development of re-entry or transition plan • Assistance to engage in community-based SA and MH treatment • Engagement in peer support and self-help networks to assist in recovery • Stable housing • Vocational training and employment support • Case management and community supervision 39 Summary of Key Points • 15% of offenders have CODs (> gen. population) • Cognitive impairment and lower functioning • Require specialized services - Blended screening and assessment - Integrated treatment - Focus on special needs (e.g., criminal thinking, trauma/PTSD) - Specialized supervision teams • Evidence-based practices are available 40 COD 102 • Screening instruments • Conceptual model to drive COD services (Risk-Need-Responsivity) • Modifying treatment for CODs • Special populations and CODs 41