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Enhancing Co-Occurring Disorder Enhancing Co-Occurring Disorder Services in Addiction Treatment:Services in Addiction Treatment:
Preliminary Findings of the Texas Preliminary Findings of the Texas Co-Occurring State Incentive Co-Occurring State Incentive
GrantGrant
Dartmouth Psychiatric Research Center SeminarDartmouth Psychiatric Research Center SeminarMay 2007May 2007
Texas COSIG Project Texas COSIG Project
The goal of the COSIG project is to improve The goal of the COSIG project is to improve the delivery of state-funded services for the delivery of state-funded services for clients in Texas with co-occurring psychiatric clients in Texas with co-occurring psychiatric and substance use disorders (COPSD).and substance use disorders (COPSD).
The project consists of two components The project consists of two components designed to promote system change and to designed to promote system change and to enhance specialized clinical skills of enhance specialized clinical skills of providers treating COPSD.providers treating COPSD.
COSIG Project Component #1COSIG Project Component #1
Focused education at the clinician level Focused education at the clinician level regarding treatment issues relevant to regarding treatment issues relevant to COPSD and training on the use of COPSD and training on the use of diagnostic and assessment instruments to diagnostic and assessment instruments to enhance identification of psychiatric enhance identification of psychiatric comorbidity and monitor progress of comorbidity and monitor progress of clients.clients.
COPSD Curriculum ModulesCOPSD Curriculum Modules
Module 1: Substance Use and Mental Health DisordersModule 1: Substance Use and Mental Health Disorders
Module 2: Depression and Substance Use DisordersModule 2: Depression and Substance Use Disorders
Module 3: Substance Use and Bipolar DisordersModule 3: Substance Use and Bipolar Disorders
Module 4: Anxiety and Substance UseModule 4: Anxiety and Substance Use
Module 5: Schizophrenia, Schizoaffective, and SubstanceModule 5: Schizophrenia, Schizoaffective, and Substance Use DisordersUse Disorders
Module 6: Substance Use – Motives and ConsequencesModule 6: Substance Use – Motives and Consequences
Module 7: Principles of TreatmentModule 7: Principles of Treatment
Module 8: Relapse Prevention Module 8: Relapse Prevention
Diagnostic and Assessment MeasuresDiagnostic and Assessment Measures
Mini International Neuropsychiatric Interview (MINI)Mini International Neuropsychiatric Interview (MINI)
Brief Symptom Inventory (BSI)Brief Symptom Inventory (BSI)
Brief Derogatis Psychiatric Rating Scale (BDPRS)Brief Derogatis Psychiatric Rating Scale (BDPRS)
Substance Abuse Treatment Scale (SATS)Substance Abuse Treatment Scale (SATS)
Ancillary Service AssessmentAncillary Service Assessment
Client Evaluation of Self in Treatment (CEST)Client Evaluation of Self in Treatment (CEST)
Counselor Comments on Use of Diagnostic Counselor Comments on Use of Diagnostic and Assessment Measuresand Assessment Measures
Repeated administration of the MINI has increased Repeated administration of the MINI has increased understanding of disorders and enhanced ability to understanding of disorders and enhanced ability to recognize potential symptomsrecognize potential symptoms
Using results of measures has assisted in “bridging a Using results of measures has assisted in “bridging a gap” by facilitating interactions with mental health gap” by facilitating interactions with mental health providersproviders
Administration can enhance client awareness of COD Administration can enhance client awareness of COD issues – many have never been asked these questions issues – many have never been asked these questions beforebefore
Results highlight issues to be addressed in sessions with Results highlight issues to be addressed in sessions with clients and provide a means to monitor progressclients and provide a means to monitor progress
COSIG Project Component #2COSIG Project Component #2
A voucher system that provides A voucher system that provides additional funding for procurement of additional funding for procurement of ancillary services in an effort to address ancillary services in an effort to address the multifaceted needs of COPSD clients the multifaceted needs of COPSD clients and to support the treatment and and to support the treatment and recovery process ($1,800 per client).recovery process ($1,800 per client).
Voucher Service CategoriesVoucher Service Categories
Child CareChild Care
Housing SupportHousing Support
TransportationTransportation
Food AssistanceFood Assistance
Education SupportEducation Support
Employment AssistanceEmployment Assistance
ClothingClothing
Medical CareMedical Care
PrescriptionsPrescriptions
Peer MentoringPeer Mentoring
Administration of Evaluation MeasuresAdministration of Evaluation Measures
CLINICIAN
CLIENT
Ancillary ServicesAssessment
BHIPS Termination
TERMINATION
BDPRS
SATS
BSI
Motivation & Treatment
FOLLOW-UP
60-Day FU
MONTHLYADMISSION
BHIPS Assessment
MINI Diagnostic
BDPRS
BHIPS
SATS
Motivation Scales
BHIPS Wrap-Around
BDPRS
BSIBSI
CEST Treatment
Assessment
SATS
Process ScalesProcess Scales
Ancillary Services
CEST TreatmentCEST TreatmentMotivation & Treatment
COSIG Treatment ProvidersCOSIG Treatment Providers
Lubbock Regional MHMR Center
Hill Country MHMR Center Montrose
Counseling Center
Fort Bend Council on Family and
Community Development, Inc.
Association for the Advancement of
Mexican Americans, Inc.
Homeward Bound, Inc.
Nexus Recovery Center, Inc. --AND--Homeward Bound, Inc.
Northeast Texas Council on Alcoholism and Drug Abuse
Central Texas Council on Alcoholism and Drug Abuse
Santa Maria Hostel, Inc
Program Summary Program Summary ReportsReports
Psychiatric Diagnostic Impressions Psychiatric Diagnostic Impressions Program X and COSIG StatewideProgram X and COSIG Statewide
(Data through March 2007)(Data through March 2007)
64%
30%
2%
11%
26%
30%
41%
3%
28%
49%
38%
3%
11%
22%
29% 28%
7%
41%
BIPOLAR DEPRESSION HYPOMANIC DYSTHYMIA PANIC OCD PTSD PSYCHOTIC GEN ANXIETY
PROGRAM X (N = 116) COSIG STATE (N = 786)
Substance Use DisordersSubstance Use DisordersProgram X and COSIG StatewideProgram X and COSIG Statewide
(Data through March 2007)(Data through March 2007)
18%
33%
49%
14%
37%
50%
ALCOHOL ONLY DRUG ONLY ALCOHOL AND DRUG
PROGRAM X (N = 116) COSIG STATE (N = 786)
s
BSI Scores in the Clinically Significant RangeBSI Scores in the Clinically Significant RangeProgram X and COSIG StatewideProgram X and COSIG Statewide
(Data through March 2007)(Data through March 2007)
24%
22%
12%13%
21%
10%
18%
12%10%
22%
28%
21%
17%
13%15% 15%
18%
22%
19%
28%
SOM OC IS DEP ANX HOS PHOB PAR PSY GSI
PROGRAM X (N = 116) COSIG STATE (N = 756)
BDPRS Ratings in the Marked to Extreme RangeBDPRS Ratings in the Marked to Extreme RangeProgram X and COSIG StatewideProgram X and COSIG Statewide
(Data through March 2007)(Data through March 2007)
28%
42%
50%
46%44%
7%5%
9%
3%
55%
21%19%
32%35%
32%
9%
13% 14%10%
25%
SOM OC IS DEP ANX HOS PHOB PAR PSY GPI
Program X (N = 115) COSIG STATE (N = 756)
BSI and BDPRS Scores in the Clinically Significant RangeBSI and BDPRS Scores in the Clinically Significant RangeProgram X (N = 115)Program X (N = 115)
(Data through March 2007)(Data through March 2007)
24%22%
12% 13%
21%
10%
18%
12%10%
22%
28%
42%
50%
46%44%
7%5%
9%
3%
55%
SOM OC IS DEP ANX HOS PHOB PAR PSY GSI
BSI Client Self-Report BDPRS Clinician Ratings
BDPRS and BSI Scores in the Clinically Significant RangeBDPRS and BSI Scores in the Clinically Significant RangeCOSIG Statewide (N = 756)COSIG Statewide (N = 756)
(Data through March 2007)(Data through March 2007)
28%
21%
17%
13%15% 15%
18%
22%
19%
28%
21%
19%
32%
35%
32%
9%
13% 14%
10%
25%
SOM OC IS DEP ANX HOS PHOB PAR PSY GSI
BSI Client Self-Report BDPRS Clinician Ratings
SATS Ratings at Admission to COSIGSATS Ratings at Admission to COSIGProgram X and COSIG StatewideProgram X and COSIG Statewide
(Data through March 2007)(Data through March 2007)
1%
7%
24%
9%
34%
22%
3%
0%1%2%
35%
13%
20%23%
6%
0%
Pre-Engagement
Engagement EarlyPersuasion
LatePersuasion
Early ActiveTreatment
Late ActiveTreatment
RelapsePrevention
In Remissionor Recovery
PROGRAM X (N = 116) COSIG STATE (N = 781)
BSI Scale Averages at Admission and One Month in COSIGBSI Scale Averages at Admission and One Month in COSIGProgram X (N = 47)Program X (N = 47)
(Data through March 2007)(Data through March 2007)
40
45
50
55
60
SOM OC IS DEP ANX HOS PHOB PAR PSY GSI
ADMISSION ONE MONTH IN COSIG
BDPRS Averages at Admission and One Month in COSIGBDPRS Averages at Admission and One Month in COSIGProgram X (N = 47)Program X (N = 47)
(Data through March 2007)(Data through March 2007)
0
1
2
3
4
5
6
SOM OC IS DEP ANX HOS PHOB PAR PSY GPI
ADMISSION ONE MONTH IN COSIG
BSI Scores in the Clinically Significant Range BSI Scores in the Clinically Significant Range at Admission and One Month in COSIGat Admission and One Month in COSIG
Program X (N = 47)Program X (N = 47)(Data through March 2007)(Data through March 2007)
19%
26%
9%
6%
17%
13%
19%
11% 11%
13%
9%
13%
4% 4%
6%
9%
6%
11%
13%
9%
SOM OC IS DEP ANX HOS PHOB PAR PSY GSI
ADMISSION ONE MONTH IN COSIG
BDPRS Ratings in the Marked to Extreme Range BDPRS Ratings in the Marked to Extreme Range at Admission and One Month in COSIGat Admission and One Month in COSIG
Program X (N = 47)Program X (N = 47)(Data through March 2007)(Data through March 2007)
30%
34%
62%
47%
40%
11%
6%9%
4%
48%
15%
43%
60%
32%30%
2%4%
11%
2%
36%
SOM OC IS DEP ANX HOS PHOB PAR PSY GPI
ADMISSION ONE MONTH IN COSIG
SATS Ratings at Admission and One Month in COSIGSATS Ratings at Admission and One Month in COSIGProgram X (N = 47)Program X (N = 47)
(Data through March 2007)(Data through March 2007)
2%4%
11%9%
38%
30%
6%
0%0%2% 2%
0%
23%
62%
11%
0%
Pre-Engagement
Engagement EarlyPersuasion
LatePersuasion
Early ActiveTreatment
Late ActiveTreatment
RelapsePrevention
In Remissionor Recovery
ADMISSION ONE MONTH IN COSIG
Voucher Services Needed and Received Voucher Services Needed and Received at One Month in COSIG (Client Report)at One Month in COSIG (Client Report)
Program X (N = 47)Program X (N = 47)(Data through March 2007)(Data through March 2007)
0%
79%
5%
15%
0%
5%
2%
36%
21%
2%
5%
84%
7%
24%
14%
12%
7%
47%
28%
21%
Child Care
Housing Support
Transportation
Food Assistance
Education Support
Employment Assistance
Clothing
Medical Care
Prescriptions
Peer Mentoring
RECEIVED SERVICE NEEDED SERVICE
Programs Value Regular FeedbackPrograms Value Regular Feedback
Provider reported uses of data reports:Provider reported uses of data reports:
Internal monitoring of COSIG program implementationInternal monitoring of COSIG program implementation
Greater understanding of COD client characteristics and Greater understanding of COD client characteristics and individual needs to guide programmingindividual needs to guide programming
Board of Directors and Executive Management Team Board of Directors and Executive Management Team presentationspresentations
Presentations to other community service providers to Presentations to other community service providers to enhance networking (i.e., probation department, enhance networking (i.e., probation department, homeless alliances, planning and advisory committees)homeless alliances, planning and advisory committees)
Data for grant and other funding applicationsData for grant and other funding applications
Preliminary OutcomesPreliminary Outcomes
Client and Service Client and Service Characteristics Associated Characteristics Associated with Treatment Completionwith Treatment Completion
COSIG Client OutcomesCOSIG Client Outcomes
Data were obtained for 424 COSIG clients who Data were obtained for 424 COSIG clients who entered and were discharged from substance entered and were discharged from substance abuse treatment during the period of February abuse treatment during the period of February 2005 through October 20062005 through October 2006
76% of the sample completed treatment76% of the sample completed treatment
Treatment completers (n=323) and non-Treatment completers (n=323) and non-completers (n=101) were compared on client completers (n=101) were compared on client and service characteristicsand service characteristics
Client DemographicsClient Demographics
Treatment completers were more likely to Treatment completers were more likely to be male (51% vs. 34%) and homeless be male (51% vs. 34%) and homeless (24% vs. 14%)(24% vs. 14%)
The groups did not differ in race/ethnicity, The groups did not differ in race/ethnicity, education, age, marital status, education, age, marital status, employment, or past year substance-employment, or past year substance-related arrestsrelated arrests
MINI Diagnostic ImpressionsMINI Diagnostic Impressions
0%
10%
20%
30%
40%
50%
60%
BIPOLAR DEPRESSION HYPOMANIC DYSTHYMIA PANIC OCD PSYCHOTIC GENANXIETY
PTSD
COMPLETER NON-COMPLETER
*
**
*
Psychiatric Symptom SeverityPsychiatric Symptom Severity
No differences were found in client-No differences were found in client-reported symptom severity on the Brief reported symptom severity on the Brief Symptom Inventory scalesSymptom Inventory scales
Clinicians rated non-completers as having Clinicians rated non-completers as having more severe symptoms on the more severe symptoms on the interpersonal sensitivity, depression, and interpersonal sensitivity, depression, and hostility scales on the Brief Derogatis hostility scales on the Brief Derogatis Psychiatric Rating ScalePsychiatric Rating Scale
Primary Substance of AbusePrimary Substance of Abuse
0%
5%
10%
15%
20%
25%
30%
35%
40%
ALCOHOL COCAINE CRACK OPIATES MARIJUANA OTHER
COMPLETER NON-COMPLETER
Substance Use PatternsSubstance Use Patterns
Completers reported a greater primary Completers reported a greater primary substance use during the month prior to substance use during the month prior to admission (15 vs.12 days)admission (15 vs.12 days)
A greater percentage of non-completers A greater percentage of non-completers reported polysubstance use (56% vs. 42%)reported polysubstance use (56% vs. 42%)
No differences were found in total years of No differences were found in total years of primary substance use or history of IV drug useprimary substance use or history of IV drug use
Substance Abuse Treatment HistorySubstance Abuse Treatment History
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
PRIOR DETOX PRIOR NON-DETOX AA PAST 30 DAYS
COMPLETERS NON-COMPLETERS
*
*
*
Discharge CharacteristicsDischarge Characteristics
Completers had higher past month Completers had higher past month abstinence rates (88% vs. 61%)abstinence rates (88% vs. 61%)
Completers had higher past month AA Completers had higher past month AA attendance (95% vs. 78%)attendance (95% vs. 78%)
No group differences were found in length No group differences were found in length of stay in treatment (approximately 100 of stay in treatment (approximately 100 days)days)
Voucher Service UtilizationVoucher Service Utilization
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
CHILDCARE
VOCATIONAL
PRESCRIPTIONS
MEDICAL
CLOTHING
EDUCATION
PEER MENTORING
FOOD
TRANSPORTATION
HOUSING
COMPLETER NON-COMPLETER
**
*
*
*
Recovery and Social Support Recovery and Social Support Service CombinationsService Combinations
0%
10%
20%
30%
40%
50%
60%
70%
PEER MENTORING AND SOCIAL SUPPORT SOCIAL SUPPORT ONLY
COMPLETER NON-COMPLETER
*
*
ConclusionsConclusions
Higher treatment completion for males indicates Higher treatment completion for males indicates that women with COD may need specialized that women with COD may need specialized interventions in substance abuse treatmentinterventions in substance abuse treatment
A study analyzing gender differences using a A study analyzing gender differences using a subset of these data revealed that women subset of these data revealed that women demonstrated higher awareness of psychiatric demonstrated higher awareness of psychiatric issues relative to substance abuse problems, issues relative to substance abuse problems, suggesting that substance abuse treatment suggesting that substance abuse treatment inventions may need greater focus on the inventions may need greater focus on the interaction of the two disorders* interaction of the two disorders*
*(Mangrum, Spence, & Steinley-Bumgarner, 2006)*(Mangrum, Spence, & Steinley-Bumgarner, 2006)
ConclusionsConclusions
Lower completion rates for clients with Lower completion rates for clients with bipolar and posttraumatic stress disorders bipolar and posttraumatic stress disorders suggest that these syndromes may be suggest that these syndromes may be more difficult to treat in substance abuse more difficult to treat in substance abuse treatment settings treatment settings
Substance abuse counselors may need Substance abuse counselors may need training on specific interventions targeting training on specific interventions targeting these two disordersthese two disorders
ConclusionsConclusions
The 76% completion rate for the total sample is higher The 76% completion rate for the total sample is higher than previously calculated statewide averages, than previously calculated statewide averages, suggesting that the provision of recovery and social suggesting that the provision of recovery and social support services may enhance treatment outcomessupport services may enhance treatment outcomes
A study examining clients receiving COPSD services in A study examining clients receiving COPSD services in Texas during FY 2004 revealed a 57% completion rate* Texas during FY 2004 revealed a 57% completion rate*
Other analyses of general substance abuse treatment Other analyses of general substance abuse treatment clients in Texas have indicated completion rates ranging clients in Texas have indicated completion rates ranging from 51 - 54% from 51 - 54%
*(Mangrum & Spence, 2005)*(Mangrum & Spence, 2005)
ConclusionsConclusions
Peer mentoring had the strongest association Peer mentoring had the strongest association with treatment completionwith treatment completion
Social support services, particularly in the Social support services, particularly in the absence of peer mentoring, were associated absence of peer mentoring, were associated with non-completionwith non-completion
Similar trends have been found in the Texas Similar trends have been found in the Texas ATR voucher service data, indicating that direct ATR voucher service data, indicating that direct recovery support services are associated with recovery support services are associated with greater completion rates, whereas the provision greater completion rates, whereas the provision of social support services only is more highly of social support services only is more highly associated with non-completionassociated with non-completion
DDCAT AssessmentsDDCAT Assessments
Preliminary ResultsPreliminary Results
Overall DDCAT ScoresOverall DDCAT Scores
2.69
4.57
3.273.05
3.41
2.89
3.19
A1 A2-OP A2-R A3-OP A3-R A4 A5
DDE: 5
DDC: 3
AOS: 1
Dual Diagnosis Capability ClassificationsDual Diagnosis Capability Classifications
DDC 3
AOS 4
DDE 1
DDC 4
AOS / DDC 2
Criterion Method Scoring Scale Method Scoring
DDCAT Scale Scores by ProgramDDCAT Scale Scores by Program
A1
A2-OP
A2-R
A3-0P
A3-R
A4A5
PS PM CP:A CP:T CC S T
DDE: 5
DDC: 3
AOS: 1
Average DDCAT Scale Scores StatewideAverage DDCAT Scale Scores Statewide
PS PM CP:A CP:T CC S T
DDE: 5
DDC: 3
AOS: 1