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The Prevalence, Co-morbidity, and Treatment of Mental Health, Substance, and Crime Problems among Teenagers
Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, ILPresentation at “Pediatric Mental Health Primer V: The Complex Needs of Children with Dual Diagnosis (Mental Illness and Substance Abuse)”, September 18, 2007, InPlay’s Forté Conference Center, Peoria, IL. The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 and several individual grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: [email protected]
2
1. To examine the prevalence, course, and consequences of adolescent substance use and co-occurring disorders and the unmet need for treatment
2. To summarize major trends, variability and problems in the adolescent treatment system
3. To present the findings from several recent treatment outcome studies on substance abuse treatment research, trauma and violence/crime.
Goals of this Presentation
3
Severity of Past Year Substance Use/Disorders by Age
Source: 2002 NSDUH and Dennis & Scott in press
0
10
20
30
40
50
60
70
80
90
100
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
65+
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
Abuse
Dependence
NSDUH Age Groups
Severity CategoryAdolescent
OnsetRemission
Increasing rate of non-
users
2002 U.S. Household Population age 12+ = 235,143,246
4
Higher Severity is Associated with Higher Annual Cost to Society Per Person
Source: 2002 NSDUH
$0$231 $231
$725$406
$0$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
No Alcohol orDrug Use
Light Alcohol
Use Only
AnyInfrequentDrug Use
Regular AODUse
Abuse Dependence
Median (50th percentile)
$948
$1,613
$1,078$1,309
$1,528
$3,058Mean (95% CI)
This includes people who are in recovery, elderly, or do not use
because of health problems Higher Costs
5
Substance Use Careers Last for Decades C
um
ula
tive
Su
rviv
al
Years from first use to 1+ years abstinence302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 27 years from
first use to 1+ years
abstinence
Source: Dennis et al., 2005
6
Substance Use Careers are Longer the Younger the Age of First Use
Cu
mu
lati
ve S
urv
ival
Years from first use to 1+ years abstinence
under 15*
21+
15-20*
Age of 1st UseGroups
* p<.05 (different from 21+)
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Source: Dennis et al., 2005
7
Substance Use Careers are Shorter the Sooner People Get to Treatment
Cu
mu
lati
ve S
urv
ival
20+
0-9*
10-19*
Year to 1st TxGroups
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
* p<.05 (different from 20+)Source: Dennis et al., 2005
Years from first use to 1+ years abstinence
8
Treatment Careers Last for Years C
um
ula
tive
Su
rviv
al
Years from first Tx to 1+ years abstinence2520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 3 to 4 episodes of treatment over 9 years
Source: Dennis et al., 2005
9
Need for Treatment (% of 24,753,586 Adolescents in the U.S. Household Population)
Source: NSDUH and TEDS (see state level estimates in appendix)
8.9%
0.7%
0.6%
5.7%
8.1%
11.5%
10.7%
14.9%
17.8%
0% 5% 10%
15%
20%
25%
Tobacco
Alcohol
Alcohol Binge
Any Drug Use
Marijuana Use
Any Non-Marijuana Drug Use
Past Year AOD Dependence or Abuse
Any Treatment (From NHSDA)
Public Treatment (From TEDS)
--
----
--P
ast M
onth
Use
----
--
Less than 1 in 10 getting treatment
88% of adolescents are treated in the
public system
10
Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment)
Prevalence82.4 to 90.1%90.2 to 92.3%92.4 to 94.2%94.3 to 98.0%U.S.Avg.=92.2%IL=92.5%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )
9 in 10 Untreated
11
Adolescent Treatment Admissions have increased by 61% over the past decade
Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)http://www.samhsa.gov/oas/dasis.htm
64% increase from95,271 in 1993
to 158,723 in 2005
12
Severity Goes up with Level of Care
Source: Treatment Episode Data Set (TEDS) 1993-2003.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Weekly useat intake
First usedunder age 15
Dependence Prior Treatment
Case Mix Index (Avg)
Outpatient Intensive Outpatient DetoxificationLong-term Residential Short-term Residential
STR: Higher on
Dependence
Baseline Severity Goes up with Level
of CareDetox: Higher on Use
Detox: Higher on Use, but lower on prior tx
13
Median Length of Stay is only 50 days
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
0 30 60 90
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Lev
el o
f C
are
Median Length of Stay
50 days
49 days
46 days
59 days
21 days
3 days
Less than 25% stay the
90 days or longer time
recommended by NIDA
Researchers
14
53% Have Unfavorable Discharges
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
Despite being widely recommended, only 10% step down after intensive treatment
0% 20% 40% 60% 80% 100%
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Completed Transferred ASA/ Drop out AD/Terminated
15
Most Lack of Standardized Assessment for…
Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment
Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidality)
Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)
HIV risk behaviors (needle use, sexual risk, victimization)
Child maltreatment (physical, sexual, emotional)
16
GAIN Clinical CollaboratorsAdolescent and Adult Treatment Program
7/07
VI
01 to 1011 to 2526 to 100
DE
HI
ID
IN
KS
LA
MS
MT ND
PR
SDWY
ME
NH
AK
AR
IA
MO
OK
WV
AL
CO
NM
NV
MI
NJ
VT
NE
WA
WI NY
PARI
SC
OR
FL
UTVA
NCTN
MN
KY
TX
GA
MD
AZ
CT
IL
MA
CA
OH
DC
One or more state or county wide systems uses the GAIN
17
CSAT Adolescent Treatment (AT)Outcome Data SetRecruitment: 1998-2006 (updated annually)
Sample: The 2006 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 12,690 adolescents from 96 local evaluations
Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care
Instrument: Global Appraisal of Individual Needs (GAIN) (see www.chestnut.org/li/gain)
Follow-up: Over 80% follow-up 3, 6, 9 & 12 months post intake
Funding: CSAT contract 270-2003-00006 and 72 individual grants
18
Level of Care (n=12,601)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Cont. Care (5%)
Detention (1%)
Long Term Resid. (7%)
Mod. Term Resid. (10%)
Short Term Resid. (3%)
Intensive OP (8%)
Outpatient (60%)
Early Intervention (6%)
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
19
Type of Treatment (n=12,601)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Other (22%)
Other ManualizedPrograms (15%)
Other Evidenced BasedTx (3%)
Adolescent CRA (3%)*
MET/CBT (51%)
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
* Data Prior to current AAFT program replicating A-CRA
20
Demographics
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
27%
19%
17%
4%
14%
19%
73%
8%
49%
31%
88%
31%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Female
Hispanic
African American
Native American
Mixed
Age <15
Age 15-17
Age >17
Single Parent
Employed
In School
Ever Homeless or Runaway
21
Recovery Environment
55%
49%
27%
73%
65%
13%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Social Peers Getting Drunk Weekly+
School/Work Peers Getting Drunk Weekly+
Others at Home Getting Drunk Weekly+
Social Peers Using Drugs
School/Work Peers Using Drugs
Others at Home Using Drugs
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
22
Past 90 day HIV Risk Behaviors
67%
37%
30%
26%
21%
2%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sexually active
Sex Under the Influence of AOD
Multiple Sex partners
Any Unprotected Sex
Victimized Physically, Sexually, orEmotionally
Any Needle use
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
23
Weekly or More Often Use in the Past 90 Days
59%
46%
16%
4%
2%
6%
53%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Substance
Marijuana
Alcohol
Crack/Other Cocaine
Heroin/Opioids
All Other Drugs
Tobacco
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
24
Substance Use Problems
83%
50%
29%
7%
34%
29%
26%
94%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Past Year Substance Diagnosis
Any Past Year Dependence
Any withdrawal symptoms in the past week
Severe withdrawal (11+ symptoms) in past week
Can Give 1+ Reasons to Quit
Any prior substance abuse treatment
Acknowledges having an AOD problem
Client believes Need ANY Treatment
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
25
Prevalence of Past Year Substance Use Disorder by Age
Source: Chan, Dennis & Funk in press
26
Co-Occurring Psychiatric Problems
52%
44%
36%
25%
15%
64%
46%
31%
24%
11%
67%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Co-occurring Psychiatric
Conduct Disorder
Attention Deficit/Hyperactivity Disorder
Major Depressive Disorder
Traumatic Stress Disorder
General Anxiety Disorder
Ever Physical, Sexual or Emotional Victimization
High severity victimization (GVS>3)
Ever Homeless or Runaway
Any homicidal/suicidal thoughts past year
Any Self Mutilation
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
27
Prevalence of Substance, Internalizing and Externalizing Disorders by Age
Source: Chan, Dennis & Funk in press
0
20
40
60
80
100
<15 15-17 18-25 25-39 40+
Age groups
Pre
va
len
ce
(%
)
Substance
Internalizing
Externalizing
Both internaland external
28
Past Year Violence & Crime
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
81%
68%
65%
49%
47%
44%
84%
69%
38%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any violence or illegal activity
Physical Violence
Any Illegal Activity
Any Property Crimes
Other Drug Related Crimes*
Any Interpersonal/ Violent Crime
Lifetime Juvenile Justice Involvement
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
29
Intensity of Juvenile Justice System Involvement
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
Other prob/ parole/
detention, 16%
Other JJ status, 17%
Past arrest/JJ
status, 7%
Past year illegal
activity/SA use, 20%
Probation/ Parole with
urine monitoring,
24%
Detention 14+ Days,
16%
30
Relationship of Level of Care to theNumber of Major Clinical Problems
Source: CSAT 2006 AT Outcome Data Set (n=12,601); Odds Ratio (OR) of having 5+ of 12 problems (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
31
Relationship of Victimization to theNumber of Major Clinical Problems
Source: CSAT 2006 AT Outcome Data Set (n=12,601); Odds Ratio (OR) of having 5+ of 12 problems (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
32
Treatment Outcomes by Level of Care: Days of AOD Abstinence*
* Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change)
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
0
30
60
90
Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Day
s of
Ab
stin
ence
(of
90)
Outpatient (+21%, -1%)
Residential (+83%, -10%)
Cont. care (+17%, -11%)
33
Treatment Outcomes by Level of Care: Recovery*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Per
cen
t in
Pas
t M
onth
Rec
over
y*
Outpatient (+97%, +2%)
Residential (+115%, +9%)
Cont. care (+165%, +27%)
* Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change)
Source: CSAT 2006 AT Outcome Data Set (n=12,601)
34
Change in Substance Frequency Scaleby Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,ts
OP\t,s,ts
Residential programs start more severe, go down sharply,
but then come back over time
Note the sharp “hinge” in outcomes
during the active phase of AOD
treatment
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
35
Pattern of SA Outcomes is Related to the Pattern of Psychiatric Multi-morbidity
Source: Shane et al 2003, PETSA data
Months Post Intake (Residential only)0 3 6 12
Nu
mb
er o
f P
ast
Mon
th S
ub
stan
ce P
rob
lem
s
2+ Co-occurring 1 Co-occurring No Co-occurring
Multi-morbid Adolescents start the highest, change the most, and relapse the most
36
Change in Emotional Problem Scale by Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,s,ts
OP\t,s
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
Note the lack of a hinge; Effect is generally indirect (via
reduced use) not specific
37
Victimization and Level of Care Interact to Predict Outcomes
Source: Funk, et al., 2003
0
5
10
15
20
25
30
35
40
Intake 6 Months Intake 6 Months
Mar
ijua
na U
se (
Day
s of
90)
OP -High OP - Low/Mod Resid-High Resid - Low/Mod.
CHS Outpatient CHS Residential Traumatized groups have higher severity
High trauma group does not respond to OP
Both groups respond to residential treatment
38
Are there other more effective OP programs?
Source: CYT and ATM Outpatient Data Set Dennis 2005
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Z-S
core
on
Sub
stan
ce F
requ
ency
Sca
le (
SF
S) CYT Total (n=217; d=0.51)
CHSOP (n=57; d=0.18)
And on average the CYT have moderate effect sizes
even with high GVS
Green line is CHS OP’s High GVS adolescents; they have some initial gains but substantial relapse
39
Change in Illegal Activity Scaleby Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
40
50
60
Intake 3 6 9 12
Months from Intake
STR\t,s,ts
LTR\t,ts
OP\s
Short- Term Resid. \t,s,ts
Long- Term Resid\t,ts
Outpatient\t,s
Residential Treatments have a specific effect
Outpatient Treatments has an indirect effect
40
Randomly Assigns to:
MET/CBT5Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Trial 2Trial 1Incremental Arm Alternative Arm
Cannabis Youth Treatment (CYT) Experiments
ACRAAdolescent Community
Reinforcement Approach(12 weeks)
MDFTMultidimensional Family Therapy
Randomly Assigns to:
MET/CBT5Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
(12 weeks)
Source: Dennis et al, 2002
41
5
10
5
11
14
23
0
5
10
15
20
25
MET/CBT5
MET/CBT12
MET/CBT12 +
FSN
MET/CBT5
ACRA MDFT
Hou
rs
Day
s
CaseManagement
FamilyCounseling
Collateral only
Multi-Familygroup
Multi-ParticipantGroup
Participant only
Incremental Arm Alternative Arm
Actual Treatment Received by Condition
Source: Dennis et al, 2004
MET/CBT12 adds 7 more sessions of
group
FSN adds multi family group,
family home visits and more case management
ACRA and MDFT both rely on
individual, family and case management instead of group
With ACRA using more individual therapy
And MDFT using more
family therapy
42
$1,559$1,413
$1,984
$3,322
$1,197$1,126
$-
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
MET/C
BT5 (6.8
wee
ks)
MET/C
BT12 (1
3.4 w
eeks
)
FSN (14.2
wee
ks w
/family
)
MET/C
BT5 (6.5
wee
ks)
ACRA (12.8
wee
ks)
MDFT(1
3.2 w
eeks
w/fa
mily)
$1,776
$3,495
NTIES E
st (6
.7 wee
ks)
NTIES E
st.(1
3.1 w
eeks
)
Ave
rage
Cos
t P
er C
lien
t-E
pis
ode
of C
are
|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|
Average Episode Cost ($US) of Treatment
Source: French et al., 2002
Less than average
for 6 weeks
Less than average
for 12 weeks
Integrating family therapy
was less expensive
than adding it
43
Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS*
Source: Tims et al, 2002
85%
46%
26%
78%
26%
47%
26%
71%
0%
20%
40%
60%
80%
100%
First usedunder age
15
Dependence Weekly ormore use at
intake
PriorTreatment
% o
f A
dm
issi
on
s
.
CYT Outpatient(n=600) TEDS Outpatient (n=16,480)* Adolescents with marijuana problems admitted to outpatient treatment
44
Multiple Problems were the NORM
86%
37%
12%
25%
61%
60%
66%
83%
83%
0% 20% 40% 60% 80% 100%
Any Marijuana Use Disorder
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
Any External Disorder
Lifetime History of Victimization
Acts of Physical Violence
Any (other) Illegal Activity
Three to Twelve Problems
Self-Reported in Past Year
Source: Dennis et al, 2004
45
Substance Use Severity was Related to Other Problems
* p<.05
Source: Tims et al 2002
71%
57%
25%
42%
30%37%
22%
5%
13%
22%
0%
20%
40%
60%
80%
100%
Health ProblemDistress*
Acute MentalDistress*
AcuteTraumaticDistress*
AttentionDeficit
HyperactivityDisorder*
ConductDisorder*
Past Year Dependence (n=278) Other (n=322)
46
CYT Increased Days Abstinent and Percent in Recovery*
Source: Dennis et al., 2004
0
10
20
30
40
50
60
70
80
90
Intake 3 6 9 12
Day
s A
bsti
nent
Per
Qua
rter
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% in
Rec
over
y at
the
End
of
the
Qua
rter
Days Abstinent
Percent in Recovery
*no use, abuse or dependence problems in the past month while in living in the community
47
Similarity of Clinical Outcomes by Conditions
Source: Dennis et al., 2004
200
220
240
260
280
300
Tot
al d
ays
abst
inen
t.
over
12
mon
ths
0%
10%
20%
30%
40%
50%
Per
cent
in R
ecov
ery
. at
Mon
th 1
2
Total Days Abstinent* 269 256 260 251 265 257
Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19
MET/ CBT5 (n=102)
MET/ CBT12
FSN (n=102)
MET/ CBT5 (n=99)
ACRA (n=100)
MDFT (n=99)
Trial 1 Trial 2
* n.s.d., effect size f=0.06** n.s.d., effect size f=0.12
* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16
Not significantly different by condition.
But better than the average for OP in ATM (200 days of
abstinence)
48
Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition
Source: Dennis et al., 2003; forthcoming
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
CPPR at 30 months** $6,437 $10,405 $24,725 $27,109 $8,257 $14,222
CPPR at 12 months* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5 MET/ CBT12 FSNM MET/ CBT5 ACRA MDFT
Trial 1 (n=299) Trial 2 (n=297)
Cos
t P
er P
erso
n in
Rec
over
y (C
PP
R)
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Stability of MET/CBT-5
findings mixed at 30 months
MET/CBT-5, -12 and ACRA more cost effective at
12 months
Integrated family therapy (MDFT) was more cost effective than
adding it on top of treatment (FSN) at 30 months
ACRA Effect Largely Sustained
49
Cumulative Recovery Pattern at 30 months
Source: Dennis et al, forthcoming
37% Sustained Problems
5% Sustained Recovery
19% Intermittent, currently in
recovery
39% Intermittent, currently not in
recovery
The Majority of Adolescents Cycle in and out of Recovery
50
Post Script on CYT
The CYT interventions provide replicable models of brief (1.5 to 3 month) treatments that can be used to help the field maintain quality while expanding capacity.
While a good start, the CYT interventions were still not an adequate dose of treatment for the majority of adolescents – including many who continued to vacillate in and out of recovery after discharge from CYT.
Descriptive, outcome and economic analyses have been published All five interventions are currently being used in subsequent
experiments The MET/CBT5 intervention has just been replicated in a 38 site study
and ACRA is currently being replicated in a 33 site study. Over 60,000 copies of the CYT manuals have been distributed by
NCADI and as many electronic copies have been distributed by CD or the website
Findings from the Assertive Continuing Care (ACC)
Experiment
183 adolescents admitted to residential substance abuse treatment
Treated for 30-90 days inpatient, then discharged to outpatient treatment
Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC)
Over 90% follow-up 3, 6, & 9 months post discharge
Source: Godley et al 2002, forth coming
52
Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 10 20 30 40 50 60 70 80 90
Days after Residential (capped at 90)
Per
cen
t of
Clie
nts
Cont.CareAdmis.
Relapse
53
ACC Enhancements
Continue to participate in UCC
Home Visits
Sessions for adolescent, parents, and together
Sessions based on ACRA manual (Godley, Meyers et al., 2001)
Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)
54
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuin
g Care
General Continuin
g Care Adherence
Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)
Early Abstinence
GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence
Sustained Abstinence
Early abstinence will be associated with higher rates of long term abstinence.
55
ACC Improved Adherence
Source: Godley et al 2002, forthcoming
0% 10%
20%
30%
40%
50%
60%
70%
80%
Weekly Tx Weekly 12 step meetings
Regular urine tests
Contact w/probation/school
Follow up on referrals*
ACC * p<.05
90%
100%
Relapse prevention*
Communication skills training*
Problem solving component*
Meet with parents 1-2x month*
Weekly telephone contact*
Referrals to other services*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
UCC
56
GCCA Improved Early (0-3 mon.) Abstinence
Source: Godley et al 2002, forthcoming
24%
36% 38%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)
Low (0-6/12) GCCA
43%
55% 55%
High (7-12/12) GCCA * p<.05
57
Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence
Source: Godley et al 2002, forthcoming
19% 22% 22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)
Early(0-3 mon.) Relapse
69%
59%
73%
Early (0-3 mon.) Abstainer * p<.05
58
Post script on ACC
The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence.
Despite these GAINs, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans.
The ACC preliminary findings are published and the main findings are currently under review.
Several CSAT grantees are also seeking to replicate ACC as part of the Adolescent Residential Treatment (ART) program.
A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes.
The ACC manual is being distributed via the website and the CD you have been provided.
59
A Fearless Appraisal… We are entering a renaissance of new knowledge in this area, but are only
reaching 1 of 10 in need
Several interventions work, but the majority of the adolescents are still having problems 12 months later
Effectiveness is related to severity, intervention strength, implementation/adherence, and how assertive we are in providing treatment
As other therapies have caught up technologically, there is no longer the clear advantage of family therapy found in early literature reviews
While there have been concerns about the potential iatrogenic effects of group therapy, the rates do not appear to be appreciably different from individual or family therapy if it is done well (important since group tx typically costs less)
Effectiveness was not consistently associated with the amount of therapy over a short period of time (6-12 weeks) but was related to longer term continuing care
60
Recommendations for Further Developments…
We need to target the latter phases of treatment to impact the post-treatment recovery environment and/or social risk groups that are the main predictors of long term relapse
We need to move beyond focusing on acute episodes of care to focus on continuing care and a recovery management paradigm
We need to better understand the impact of involvement in juvenile justice system and how it can be harnessed to help
More work is need on the use of schools as a location for providing primary treatment (they have entrée to the population and appear to be the venue of choice) and recovery-schools to provide support for those coming out of residential treatment
61
Other Assessment and Treatment Resources
Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gain – CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at
http://www.niaaa.nih.gov/publications/instable.htm Treatment Programs
– CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols and on CDs provided
– SAMHSA Knowledge Application Program (KAP) at http://kap.samhsa.gov/products/manuals
– NCADI at www.health.org – National Registry of Effective Prevention Programs
Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov
– NCTSN trauma intervention tool kit http://www.nctsnet.org – National Center for Mental Health and Juvenile Justice Evidence Based Practice
resource list at http://www.ncmhjj.com/EBP/default.asp Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)
www.chestnut.org/li/apss/sasate Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://
www.mayatech.com/cti/jmate/ – next meeting March 30-April 2, 2008, Baltimore, MD
62
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among adolescents and adults presenting to substance abuse treatment. Journal of Substance Abuse Treatment.Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the
elephant in our counseling rooms. Counselor, April, 36-40.Dennis, M. L., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating
marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15.Dennis, M.L., Chan, Y.F., & Funk, R.R. (2006). Development and Validation of the GAIN Short Screener (GSS) for
Internalizing, Externalizing and Substance Use Disorders and Crime/Violence Problems Among Adolescents and Adults. American Journal on the Addictions, 15 (S1), 80 - 91
Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA.
Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment, 27, 197-213.
Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment, level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
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Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN) Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL Chestnut Health Systems. Retrieve from http//www.chestnut.org/li/gain
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marijuana treatment for adolescents Economic evaluation of a multisite field experiment. Evaluation Review,27(4)421-459. Funk, R. R., McDermeit, M., Godley, S. H., & Adams, L. (2003). Maltreatment issues by level of adolescent substance abuse
treatment The extent of the problem at intake and relationship to early outcomes. Journal of Child Maltreatment, 8, 36-45.Godley, S. H., Dennis, M. L., Godley, M. D., & Funk, R. R. (2004). Thirty-month relapse trajectory cluster groups among
adolescents discharged from outpatient treatment. Addiction, 99 (s2), 129-139, Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive
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Godley, S. H., Jones, N., Funk, R., Ives, M., and Passetti, L. L. (2004). Comparing Outcomes of Best-Practice and Research-Based Outpatient Treatment Protocols for Adolescents. Journal of Psychoactive Drugs, 36, 35-48.
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References - continuedOffice of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998.
Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics
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Shane, P., Jasiukaitis, P., & Green, R. S. (2003). Treatment outcomes among adolescents with substance abuse problems: The relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning, 26, 393-402.
Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment . Addiction, 97, 46-57.
Titus, J. C., Dennis, M. L., White, W. L., Scott, C. K., & Funk, R. R. (2003). Gender differences in victimization severity and outcomes among adolescents treated for substance abuse. Journal of Child Maltreatment, 8, 19-35.
White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), 67-69.
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