copyright west institute evidence-based practices integrated dual disorder treatment (iddt)...

Evidence-Based Practices Copyright West Institute

Integrated Dual Disorder Treatment (IDDT)

Evidence Based PracticeEvidence Based Practice

Kick Off PresentationKick Off Presentation


What are dual disorders?

Mental illness and substance use disorder Mental illness and substance use disorder occurring together in one personoccurring together in one person


Why focus on dual disorders?

Substance use disorders are common in people Substance use disorders are common in people with severe mental illness with severe mental illness

Mental illness is common in people with Mental illness is common in people with substance use disorderssubstance use disorders

Dual disorders lead to worse outcomes and Dual disorders lead to worse outcomes and higher costs than single disordershigher costs than single disorders


How common are these problems in Americans?

Mental illnessMental illness• Depression 15%Depression 15%

• Anxiety Disorders 13%Anxiety Disorders 13%

• Bipolar 1%Bipolar 1%

• Schizophrenia 1%Schizophrenia 1%

Substance use disordersSubstance use disorders• Alcohol 20%Alcohol 20%

Men 30%Men 30% Women 10%Women 10%

• Drugs 9%Drugs 9% Men 11%Men 11% Women 7%Women 7%


Substance abuse is common in people with mental illness

Over 50% of people with schizophrenia, Over 50% of people with schizophrenia, bipolar disorder and other severe mood bipolar disorder and other severe mood disorders have a substance use disorder at disorders have a substance use disorder at some time in their lifesome time in their life

About one third of people with anxiety and About one third of people with anxiety and depressive disorders have a substance use depressive disorders have a substance use disorder at some time in their lifedisorder at some time in their life


Prevalence of substance use disorders in mental illness

0

10

20

30

40

50

60

% of respondents

with substance use disorder

Gen pop Schiz Bipolar Maj dep OCD Panic


Prevalence of Co-Occurring Disorders-ECA Study

0102030405060708090

100

Alcohol UseDisorder

Drug UseDisorder

Alcohol orDrug UseDisorder

SchizophreniaGeneral Population

% o

f re

spon

dent

s

Regier et al., JAMA, 1990


Prevalence of mental illness in alcohol disorder samples

0

10

20

30

40

50

60

70

Community SATreatment

In community, 24.4% In community, 24.4% have mental illness have mental illness

In institutions, 55% In institutions, 55% have mental illnesshave mental illness

In substance abuse In substance abuse treatment, 65% have treatment, 65% have mental illnessmental illness


Mild to moderatemental illness symptomsMild to moderatesubstance use disorder

Severemental illness symptomsMild to moderatesubstance use disorder

Mild to moderatemental illness symptomsSeveresubstance use disorder

Severemental illness symptomsSeveresubstance use disorder

Combination and levels of illness


Types of Dual Disorders

Three categoriesThree categories• Milder mood/anxiety disorder with substance use Milder mood/anxiety disorder with substance use

disorderdisorder• Personality disorder and substance use disorderPersonality disorder and substance use disorder• Severe mental illness and substance use disorder Severe mental illness and substance use disorder


Integrated Dual Diagnosis Treatment Implementation Materials

Materials focus on treatment for persons with Materials focus on treatment for persons with severe and persistent mental illness and severe and persistent mental illness and substance use disordersubstance use disorder• Psychotic disordersPsychotic disorders• Bipolar disordersBipolar disorders• Other severely disabling mental disordersOther severely disabling mental disorders• Any level of co-occurring substance use disorderAny level of co-occurring substance use disorder


Course of dual disorders

Both substance use disorders and severe mental Both substance use disorders and severe mental illness are chronic, waxing and waningillness are chronic, waxing and waning

Recovery from mental illness or substance Recovery from mental illness or substance abuse occurs in stages over timeabuse occurs in stages over time

• PrecontemplationPrecontemplation• ContemplationContemplation• PreparationPreparation• ActionAction• MaintenanceMaintenance

Prochaska, DiClemente, and Norcross 1992; Prochaska, DiClemente, and Norcross 1992; Miller and Rollnick 1991Miller and Rollnick 1991


Course of dual disorders

People SMI and social substance usePeople SMI and social substance use Become abstinent or develop substance use disorderBecome abstinent or develop substance use disorder Can’t tolerate social useCan’t tolerate social use

People with People with more severemore severe substance use substance use disorders disorders

Most get worseMost get worse Bartels et al, 1995Bartels et al, 1995


Attaining remission occurs in stagesQuickTime™ and aGraphics decompressorare needed to see this picture.

0 mo. 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nt

Assessment Point

Pre-engagement

Engagement

Early Persuasion

Late Persuasion

Early Active Treatment

Late Active Treatment

Relapse Prevention

Recovered


Dual disorders lead to worse outcomes than single disorders

Relapse of mental illnessRelapse of mental illness Treatment problems and hospitalization Treatment problems and hospitalization Violence, victimization, and suicidal behaviorViolence, victimization, and suicidal behavior Homelessness and IncarcerationHomelessness and Incarceration Medical problems, HIV & Hepatitis risk behaviors and Medical problems, HIV & Hepatitis risk behaviors and

infectioninfection Family problemsFamily problems Increase service use and costIncrease service use and cost


Characteristics Associated with Medication Noncompliance

in Six-Month Longitudinal Study

Characteristics Odds Ratio 95% CI

Substance Abuse(0=none, 1=current)

8.1 2.5-26

Observed SideEffects(0=none, 1=any SE)

0.13 0.01-1.2

OutpatientContacts(0=none, 1=1-6, 3=>6)

0.53 O.25-1.1

Owen et al, Psychiatric Services 1996


Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C

0%

5%

10%

15%

20%

25%

Seroprevalnce Rates in SMISample

HIV (N=931) HBV (N=751)

HCV(N=751)

Persons with Substance Use Disorders had3 times higher chance of having HIV2 times higher chance of having HBV2. 5 times higher chance of having HCV

Rosenberg et al., A Jl Public Health, 2001


Monthly Income and Expenditures for Substances Among 105 Patients with

schizophrenia

Monthly incomeMonthly income $650$650 Disability incomeDisability income $645$645 Expenditures for illegal drugsExpenditures for illegal drugs $250$250 Expenditures for alcohol Expenditures for alcohol $10$10

• Median valuesMedian values


Costs of treatment for persons with dual disorders compared to SMI only

Treated for SubstanceUse (N=1,493)___________________

Not treated forSubstance Use(N=4,394)____

No substance use(N=10,509)______________

$22,917 $20,049 $13,930

Dickey and Azeni, Am J Public Health, 1996


Recovery

•Dual disorders are treatable •Many people attain stable remission of substance use disorders over time•Recovery encompasses other areas of adjustment

Health, work, housing, relationshipsMead et al, 2000


Traditional treatment

Treat each disorder separatelyTreat each disorder separately• May be parallel or sequentialMay be parallel or sequential

Separate treatment is NOT effectiveSeparate treatment is NOT effective


Evidence Based Practice

Definition of EBPDefinition of EBP• Research evidence that practice is more effective than Research evidence that practice is more effective than

usual treatment from multiple studies across the usual treatment from multiple studies across the countrycountry

Overview of national projectOverview of national project• Implementation kits for 6 evidence based practices for Implementation kits for 6 evidence based practices for

public mental healthpublic mental health• Several states attempting to implement each EBPSeveral states attempting to implement each EBP• National study of implementation National study of implementation

Process, feasibility, outcomesProcess, feasibility, outcomes


Integrated dual disorders treatment: What is it?

Treatment of substance use disorder and Treatment of substance use disorder and mental illness togethermental illness together• Same teamSame team• Same locationSame location• Same timeSame time• Other characteristics to be described laterOther characteristics to be described later


Why integrated treatment of dual disorders?

More effective than separate treatmentMore effective than separate treatment 10 studies show integrated treatment is more 10 studies show integrated treatment is more

effective than traditional separate treatment effective than traditional separate treatment • (Drake et al, Schiz Bull 1998 and Drake et al, Psych Services (Drake et al, Schiz Bull 1998 and Drake et al, Psych Services

2001 for summaries).2001 for summaries).


IDDT improves abstinence

Abstinence after Integrated Dual Disorder Treatment

0

10

20

30

40

50

60

70

0.00 1.00 2.00 3.00 4.00

Years

IDDTParallel


Fidelity to IDDT principles improves

abstinence McHugo et al, 1999

*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38

Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E ; n=61) vs. Low-Fidelity ACT Programs (G; n=26).

0

10

20

30

40

50

60

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.


Abstinence leads to improvements in other outcomes Drake et al, 1998

Reduce institutionalizationReduce institutionalization Reduce symptoms, suicideReduce symptoms, suicide Reduce violence, victimization, legal problemsReduce violence, victimization, legal problems Better physical health Better physical health Improve function, workImprove function, work Improve relationships and familyImprove relationships and family


Stable remission improves other aspects of life

Objective: Living situation, victimizationObjective: Living situation, victimization Subjective: overall satisfaction with life, Subjective: overall satisfaction with life,

housing, family, healthhousing, family, health


NH Dual Diagnosis Study (1989-1994 Drake et al, 1998)

Proportion of Days in Stable Community Housing

0.7

0.8

0.9

1.0

Beginning 6 months 12 months 18 months 24 months 30 months 36 months

All DD Patients (N = 203) Patients in Recovery (N = 54)

1. Proportion of days in stable community housing (regular apartment or house, not in hospital, jail, homeless setting or doubling with friends or family) increased for all dual diagnosis clients.

2. They increased more rapidly for persons in recovery (no substance abuse for at least 6 months).


NH Dual Diagnosis Study (1989-1994)

1. Percentage of persons hospitalized during each six months declined significantly for all clients.

2. It declined much more for those in recovery.

Percentage of Persons Hospitalized

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0


All DD Patients (N = 203) Patients in Recovery (N = 54)



Number of Arrests and Incarcerations (N=203)

0

10

20

30

40

50

60


Arrests Incarcerations in Jails or Prisons

Arrests and Incarcerations decline as persons treated for dual disorders recover from substance abuse.



Median Treatment Costs: Patients in Recovery (N=54)

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000


Inpatient Outpatient

1. Median treatment costs decline more for persons in recovery.2. Inpatient costs decrease.

3. There is a shift to community based treatment.4. Those who are most successful often begin with higher than

average treatment costs.


How do people obtain remission from dual disorders?

Stable housingStable housing Sober support network/familySober support network/family Regular meaningful activityRegular meaningful activity Trusting clinical relationshipTrusting clinical relationship

• Alverson et al, Com MHJ, 2000Alverson et al, Com MHJ, 2000


Treatment factors for recovery

Integration of mental health and substance Integration of mental health and substance abuse treatmentabuse treatment

Stage-wise interventionsStage-wise interventions Assertive outreach Assertive outreach Motivational counselingMotivational counseling Substance abuse counselingSubstance abuse counseling


Principles of Integrated Dual Disorder Treatment

IntegratedIntegrated• Same team of dually trained peopleSame team of dually trained people• Same location of servicesSame location of services• Both disorders treated at the same timeBoth disorders treated at the same time

Stage-wise servicesStage-wise services• Different services offered at different stages of Different services offered at different stages of

treatmenttreatment


Principles - Stagewise treatment

Precontemplation - EngagementPrecontemplation - Engagement• Outreach, practical help, crisis intervention, develop alliance, Outreach, practical help, crisis intervention, develop alliance,

assessmentassessment

Contemplation & Preparation - PersuasionContemplation & Preparation - Persuasion• Education, set goals, build awareness of problem, family Education, set goals, build awareness of problem, family

support, peer support, support, peer support,

Action - Active TreatmentAction - Active Treatment• Substance abuse counseling, medication treatments, skills Substance abuse counseling, medication treatments, skills

training, family support, self help groupstraining, family support, self help groups

Maintenance - Relapse preventionMaintenance - Relapse prevention• Relapse prevention plan, continue skills building in active Relapse prevention plan, continue skills building in active

treatment, expand recovery to other areas of lifetreatment, expand recovery to other areas of life


More treatment factors for recovery

Social support interventions Social support interventions • (groups, self help, family)(groups, self help, family)

Long term perspectiveLong term perspective Rehabilitation of skillsRehabilitation of skills

• (coping, social, leisure, work) (coping, social, leisure, work) Cultural sensitivity and competenceCultural sensitivity and competence Program fidelityProgram fidelity


Recovery model

Consumer drivenConsumer driven Unconditional respect and compassion Unconditional respect and compassion Clinician responsible for helping client with Clinician responsible for helping client with

motivation for treatmentmotivation for treatment Focus on client goals and function, not on Focus on client goals and function, not on

adherence to treatmentadherence to treatment Client choice and shared decision making are Client choice and shared decision making are

importantimportant


IDDT improves outcomes McHugo et al, 1999

*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38

Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E ; n=61) vs. Low-Fidelity ACT Programs (G; n=26).

0

10

20

30

40

50

60

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.


Program implementation:15 years in several states

60% of programs attain successful 60% of programs attain successful implementationimplementation

High fidelity to model leads to good outcomesHigh fidelity to model leads to good outcomes Without focus, fidelity erodes over timeWithout focus, fidelity erodes over time


Systems Issues

• How to integrate treatments?How to integrate treatments?• Stages of implementation: motivating, enacting, Stages of implementation: motivating, enacting,

and sustainingand sustaining• Each stage 6 months - 1 yearEach stage 6 months - 1 year

• Changes at 5 levelsChanges at 5 levels (1) Health authority(1) Health authority (2) Program leadership(2) Program leadership (3) Clinician/supervisor(3) Clinician/supervisor (4) Family(4) Family (5) Consumer(5) Consumer


Strategies for policy makers

Building consensus for the vision of integrated Building consensus for the vision of integrated dual disorder servicesdual disorder services

Conjoint planningConjoint planning Define standardsDefine standards Structural, regulatory, reimbursement, and Structural, regulatory, reimbursement, and

contracting mechanismscontracting mechanisms DemonstrationsDemonstrations Training and monitoringTraining and monitoring


Strategies for program leadership

Consensus and visionConsensus and vision Specific leaderSpecific leader Train all cliniciansTrain all clinicians Comprehensive integrationComprehensive integration RecordsRecords OutcomesOutcomes Quality assuranceQuality assurance


Strategies for clinicians and supervisors

Outcome based supervisionOutcome based supervision Knowledge baseKnowledge base New skillsNew skills

• AssessmentAssessment• Motivational treatmentMotivational treatment• Substance abuse counselingSubstance abuse counseling

Specialty trainingSpecialty training Secondary strategiesSecondary strategies


Strategies for families/supports

InformationInformation SupportSupport CollaborationCollaboration Skills and reinforcementSkills and reinforcement Advocacy and involvementAdvocacy and involvement


Strategies for consumers

InformationInformation Peer discussionPeer discussion CounselingCounseling RehabilitationRehabilitation TrainingTraining New roles - life is more persuasive than New roles - life is more persuasive than

researchresearch


Conclusions

Implementation of integrated dual disorder Implementation of integrated dual disorder treatment is challenging but critical to treatment is challenging but critical to outcomesoutcomes

Multiple strategies are helpfulMultiple strategies are helpful 3 stages for implementation: motivating, 3 stages for implementation: motivating,

enacting, and sustainingenacting, and sustaining Include all stakeholdersInclude all stakeholders

copyright west institute evidence-based practices integrated dual disorder treatment (iddt)...

Documents

substance use disorder

person mental illness

persistent mental illness

anxiety disorders

bipolar disorder

depressive disorders

severe mood disorders

levels of illness