Integrating Substance Abuse and Mental Health Services for Individuals

with Co-occurring Disorders

Funded by NIDA-R01-DA11966

Christine Grella, Ph.D.

UCLA Integrated Substance Abuse Programs

UCLA Addiction Clinic:2006 Seminars in Addiction Psychiatry

June 1, 2006

Overview

Prevalence of COD and availability of services Approaches to services integration Policy initiatives in U.S. UCLA Dual Diagnosis Study

Persons with Alcohol, Drug Abuse, or Mental Disorder in the Past Year

U.S. Population, Age 15 to 54, 1991

4.7%

11.3%

22.9%

29.5%

0

5

10

15

20

25

30

Any alcohol, drug abuse, or mental disorder

Any mental disorder

Any substance abuse/dependency

Co-existing mental disorder and

substance abusedependency

(52 Million)

(40 Million)

(20 Million)

(8 Million)

Source: Kessler et al., 1994.

Receipt of and Unmet Need for AOD and MH Services Among Adults with COD

23.9%

6.3%

8.9%

60.9%

34.2%

1.9%

11.8%

52.1%

MH TreatmentOnly

AOD TreatmentOnly

Both MH andAOD Treatment

Neither MH norAOD Treatment

Services Received Perceived Unmet Need Among Untreated Adults

Source: SAMHSA 2002 National Survey on Drug Use and Health

Individuals with COD Have Higher Rates of Treatment Utilization and

Poorer Treatment Outcomes Psychiatric symptoms Hospitalization Relapse to substance use Housing stability Psychosocial functioning Arrest and incarceration

Individuals with COD Seek Treatment in Both AOD and MH Programs

Over half of AOD outpatients had “probable MH disorder” (Watkins et al., 2004)

Clients with COD in AOD and MH settings showed “minimal differences” in severity and type of disorders (Havassy, Alvidrez, & Owen, 2004)

National data in U.S. show that 30% of individuals with AOD disorders either used or perceived an unmet need for MH services in past year (Mojtabai, 2005)

Services for COD in AOD Programs

Little increase in “comprehensive services” in outpatient drug treatment, 1990-2000 (Friedmann et al., 2003)

About half of AOD programs provided services for COD in national surveys, 1997-2002 (McFarland & Gabriel, 2004; Mojtabai, 2004)

Over half of private AOD providers “out-refer” clients with COD rather than treat on-site, 1995-2001 (Knudsen, Roman, & Ducharme, 2004)

Substance Abuse Treatment Facilities Offering Special Programs for Clients with COD,

1999-20021

1Survey reference dates were October 1 for 1999 and 2000 and March 29, 2002. Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, UFDS Survey, 1996–1999; National Survey of Substance Abuse Treatment Services (N-SSATS), 2000 and 2002.

Approaches to Services Integration Incorporate MH services into AOD treatment programs

assessment and diagnosis pharmacotherapy, med management psychotherapy

Incorporate AOD services into MH programs psychoeducation contingency management motivational interviewing relapse prevention 12-step groups

Develop “specialized” programs for COD that are fully integrated

Four-Quadrant Framework for COD

Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002

Less severemental disorder/

less severe substanceabuse disorder

More severemental disorder/

less severe substanceabuse disorder

More severemental disorder/

more severe substance

abuse disorder

Less severemental disorder/

more severe substance

abuse disorder

High severity

High severity

Lowseverity

Service Delivery for COD

Consultation between systems

Generally not eligible for public alcohol/drug or mental health services

Low to Moderate Psychiatric Symptoms/Disorders

And

Low to Moderate Severity Substance Issues/Disorders

Services provided in outpatient chemical dependency or mental health system

LOW - LOW HIGH - LOW

Collaboration between systems

Eligible for public mental health services but not alcohol/drug services

High Severity Psychiatric Symptoms/Disorders

And

Low to Moderate Severity Substance Issues/Disorders

Services provided in outpatient and inpatient mental health system

LOW - HIGH

Collaboration between systems

Eligible for public alcohol/drug services but not mental health services

Low to Moderate Psychiatric Symptoms/Disorders

And

High Severity Substance Issues/Disorders

Services provided in outpatient and inpatient chemical dependency system

HIGH - HIGH

Integration of services

Eligible for public alcohol/drug and mental health services

High Severity Psychiatric Symptoms/Disorders

And

High Severity Substance Issues/Disorders

Services provided in specialized treatment programs with cross-trained staff or multidisciplinary teams

Source: Ries, 2004

ACCESS AND INTER-SYSTEM LINKAGESDevelop a plan to create a nationwide expectation for alcohol and drug treatment such that no matter where in the human services, health, or justice system an individual appears, his or her alcohol or drug problem will be appropriately identified, assessed, referred, or treated.

National Treatment Plan Initiative - “No Wrong Door” Approach

“No Wrong Door” to Treatment

1. Assessment, referral, and treatment planning for all settings must be consistent with a “no wrong door” policy.

2. Creative outreach strategies may be needed to encourage some people to engage in treatment.

3. Programs and staff may need to change expectations and program requirements to engage reluctant and “unmotivated” clients.

4. Treatment plans should be based on clients’ needs and should respond to changes as they progress through stages of treatment.

5. The overall system of care needs to be seamless, providing continuity of care across service systems. This can only be achieved through an established pattern of interagency cooperation or a clear willingness to attain that cooperation.

REPORT TO CONGRESSON THE

PREVENTION AND TREATMENT OFCO-OCCURRING SUBSTANCE ABUSE AND

MENTAL DISORDERS

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administration

2002

Levels of Program Capacity in Co-Occurring Disorders

Treatment Guidelines for COD are Emergent, but Lack Consensus

Empirical evidence is lacking for most recommendations, particularly regarding:

need to treat patients in integrated settings sequencing of AOD and MH treatment

“Integrated treatment” is variously defined: unified treatment program, staff, approach co-location of services at primary site system-level linkages and referrals

Recommendations tend to be broad, rather than diagnosis- or setting-specific

Source: Watkins et al., 2005

UCLA Dual Diagnosis Study Project Aims

To assess AOD and MH programs with regard to service delivery and treatment approaches for COD

To compare differences in attitudes, beliefs, and perceptions between administrators and staff in AOD and MH programs

To evaluate outcomes of clients with COD who are treated in AOD programs that vary in services integration

Services for COD in Los Angeles County

AOD and MH treatment in Los Angeles County have been provided in separate and divergent service systems

Countywide initiatives have aimed to improve coordination and collaboration across the 2 systems

Partnerships have been developed between AOD and MH providers in the same area, with varying degrees of service integration

Services Coordination/Collaboration

DMH

DHS

ADPA

MH Programs

AOD Program

s

Administrators

StaffStaff

Administrators

Clients

Community Stakeholders

Familie

s

CJS Housing Health Welfare

Study entry

Service Delivery for COD in Los Angeles County

Methods Interviews and surveys were conducted with

administrators of 16 residential AOD treatment programs and 10 MH programs in Los Angeles County

Staff (N = 252) who have direct client contact were surveyed

Clients (N = 400) sampled from AOD programs were assessed at treatment entry, 6-month follow-up, and 12-month follow-up

Focus groups (n = 7) were conducted with program staff, clients, and community stakeholders

Client Data Collection

Number

310

351

400

0 100 200 300 400

12-monthFollow-ups (8/00 - 4/03)

6-monthFollow-ups

(2/00 - 10/02)

BaselineInterviews (8/99 - 4/02)

(77.5%)1

(87.8%)1

1An additional 18 clients (4.5%) were unable to be interviewed, refused to be interviewed, or were deceased. There were no significant background differences between the interviewed and non-interviewed groups.

Demographic Characteristics

58

50

47

18

35

47

0 10 20 30 40 50 60 70 80 90 100

Completed HS

> 35 years

Female

Hispanic/Other

Af-Am

White

Percent

27

38

48

55

57

0 10 20 30 40 50 60 70 80 90 100

Receives SSI disability

Referred by CJS

Employed past year

Health is good/excellent

Stable housing

Percent

Background Characteristics

Diagnosis of Mental Disorder1

Mood Disorder65%

Psychotic Disorder

35%

1Based on DSM-IV criteria

Alcohol/Drug Dependence1

23

28

44

46

68

83

0 10 20 30 40 50 60 70 80 90

Sedatives

Opioids

Amphetamines

Cannabis

Cocaine

Alcohol

Percent

1Lifetime; based on DSM-IV criteria

Treatment History

26

64

81

91

91

0 20 40 60 80 100

Dual Diagnosis Treatment

Prior Drug Treatment

Inpatient Mental Health Treatment

Self-help Participation

Outpatient Mental Health Treatment

Percent

Treatment Outcome at 6-month Follow-up (N = 351)

Still in treatment

4%

AOD use or incarcerated

46%No AOD

use/living in community*

50%

*No alcohol or drug use in past 30 days & living in the community (i.e., non-incarcerated, not in residential treatment)

Outcome Analyses

Latent variable structural equation models Baseline client characteristics

ethnicity MH status (SF-36, BSI) frequency of substance use in past 30 days

(marijuana, heroin, cocaine/crack, alcohol)

Outcome Analyses Program characteristics

specialized “dual-diagnosis” groups on-site sum of on-site psychological services percent of staff who had training in COD

Psychological service utilization no. of services received during follow-up period

Time in treatment (M = 93.1, SD = 51.5 days) Outcome variables

MH status (SF-36, BSI) frequency of substance use

Heavy Alcohol

Cocaine/Crack

Marijuana

Heroin

RAND SF-36MH

BSI

Psychological Service

Utilization

Time in Drug Treatment

.16**

.15**

.12*

.17**

-.11*

.24***

.08*

.13*

-.10*

.44***

.47***

.11*

.40***

.13*

-.14*

-.18**

.22***

-.12*

*p<.05, **p<.01, p<.001; CFI = .95, RMSEA = .039, RCFI = .95

Dual Diagnosis Groups

Heavy Alcohol

Cocaine/Crack

Marijuana

Heroin

African American

RAND SF-36MH

BSI

Number of Psychological Services

% Staff with Training in COD

.10*

-.12*

.10*

.69***

-.11*

.21***

.64***

-.08* .22***

.14*

.27***

.19**

Program Characteristics

Variables Not Related to Treatment Outcome

Client Factors

Type of psychiatric disorder

Legal, housing, or physical health status

Degree of family assistance

Quality of life, treatment history or motivation

Treatment Factors

Type of referral to treatment

Self-help participation following treatment (95% yes)

Rapport with AOD counselor

Satisfaction with AOD treatment

Conclusions

Integration of specialized services for COD in AOD treatment increases services utilization, which positively benefits client outcomes

Staff training is critical to increasing access to services for COD

African Americans had higher need for, but less access to, mental health services

Policy/Practice Implications

Continue system-wide efforts at services integration and staff training

Promote innovative service collaborations Address health disparities in access to MH

services

Gil-Rivas, V., & Grella, C.E. (2005). Treatment services and service delivery models for dually diagnosed clients: Variations across mental health and substance abuse providers. Community Mental Health Journal, 41(3), 251-266.

 Grella, C.E. (2003). Contrasting the views of substance misuse and mental health treatment providers on treating the dually diagnosed. Substance Use & Misuse, 38(10), 1427-1440.

 Grella, C.E. (2004, August). Dually diagnosed in drug treatment: Patient, treatment, and program effects. Presentation at the annual meeting of the American Psychological Association, Honolulu, Hawaii.

 Grella, C.E. (2003). Effects of gender and diagnosis on addiction history, treatment utilization, and psychosocial functioning among a dually diagnosed sample in drug treatment. Journal of Psychoactive Drugs, 35(4), 169-179.

 Grella, C.E. (2004, June). Multi-level models of outcomes of patients with co-occurring disorders. Poster presented at Complexities of Co-Occurring Conditions Conference, Washington, D.C.

 Grella, C.E., & Gilmore, J. (2002). Improving service delivery to the dually diagnosed in Los Angeles County. Journal of Substance Abuse Treatment, 23,115-122.

 Grella, C.E., Gil-Rivas, V., & Cooper, L. (2004). Perceptions of mental health and substance abuse program administrators and staff regarding service delivery to persons with co-occurring substance abuse and mental disorders. Journal of Behavioral Health Services & Research, 31(1), 38-49.

 Hamilton-Brown, A., Grella, C.E., & Cooper, L. (2002). Living it or learning it: Attitudes and beliefs about experience and expertise in treatment for the dually diagnosed. Contemporary Drug Problems, 29(4), 687-710.

References