What are dual disorders?

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Garry Hensley
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1 Evidence Based Practice Clinical skills training presentation Dianne Asher, LSCSW, LCAC What are dual disorders? Mental illness and substance use disorder occurring together in one person 1

2 Why focus on dual disorders? Substance use disorders are common in people with severe mental illness Mental illness is common in people with substance use disorders Dual disorders lead to worse outcomes and higher costs than single disorders - Drake and Brunette, Hassin et al, Arch Gen Psych 2002 Hope for recovery Recovery is The development of new meaning & purpose in life as one grows beyond the catastrophe of mental illness (and substance abuse) William Anthony Integrated dual disorder treatment is effective 2

3 Integrated dual disorder treatment program implementation 60% of programs who try attain successful implementation High fidelity to model leads to good outcomes Without focus, fidelity erodes over time Dual Disorders Definitions for Substance Use Disorders (DSM-IV) Abuse Maladaptive pattern of use for 12 months causing social, role, or legal problems Dependence Maladaptive pattern of use for 12 months with 3 or more: tolerance, withdrawal, more amount or time than intended, desire to cut down, other activities reduced, use despite problems 3

4 Epidemiology (How common are these problems?) Mental illness Substance use Depression 15% disorders Anxiety Disorders Alcohol 20% 13% Men 30% Bipolar 1% Women 10% Schizophrenia 1% Drugs 12% Men 15% Women 9% Prevalence of substance use disorders in mental illness 4

5 Course of dual disorders Both substance use disorders and severe mental illness are chronic, waxing and waning Recovery from mental illness or substance abuse occurs in stages over time Precontemplation Contemplation Preparation Action Maintenance - Prochaska, & DiClemente 1992, Miller & Rollnick 1991 Course of disorders Without treatment, people who drink socially Become abstinent or develop substance use disorder People with more severe substance use disorders Most get worse - Bartels et al,

6 Dual disorders lead to worse outcomes than single disorders Relapse of mental illness Treatment problems and hospitalization Violence, victimization, and suicidal behavior Homelessness and Incarceration Medical problems, HIV & Hepatitis risk behaviors and infection Family problems Increase service use and cost Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C 25% HIV 3.1% (0.5% in 20% general population) Hepatitis B 23.4% 15% (5% in general 10% population) 5% Hepatitis C 19.6% - 0% Seroprevalnce Rates in SMI Sample (2% in general population) HIV (N=931) HCV(N=751) HBV (N=751) Rosenberg et al., A Jl Public Health,

7 Recovery Dual disorders are treatable Many people attain stable remission of substance use disorders over time Recovery encompasses other areas of adjustment Traditional treatment Treat each disorder separately May be parallel or sequential Separate treatment is NOT effective 7

8 Integrated dual disorders treatment: What is it? Treatment of substance use disorder and mental illness together Same team Same location Same time Other characteristics ti to be described d later Integrated treatment IS effective Why integrated treatment of dual disorders? More effective than separate treatment 10 studies show integrated treatment is more effective than traditional separate treatment (Drake et al, Schiz Bull 1998 and Drake et al, Psych Services 2001 for summaries). 8

9 IDDT improves abstinence outcomes Abstinence after Integrated t Dual Disorder Treatment Years IDDT Parallel NH Dual Diagnosis Study ( ) Proportion of Days in Stable Community Housing Beginning 6 months 12 months 18 months 24 months 30 months 36 months All DD Patients (N = 203) Patients in Recovery (N = 54) 9

10 NH Dual Diagnosis Study ( ) Percentage of Persons Hospitalized Beginning 6 months 12 months 18 months 24 months 30 months 36 months All DD Patients (N = 203) Patients in Recovery (N = 54) NH Dual Diagnosis Study ( ) Number of Arrests and Incarcerations (N=203) Beginning 6 months 12 months 18 months 24 months 30 months 36 months Arrests Incarcerations in Jails or Prisons 10

11 NH Dual Diagnosis Study ( ) Median Treatment Costs: Patients in Recovery (N=54) $ 14,000 $ 12,000 $ 10,000 $ 8,000 $ 6,000 $ 4,000 $ 2,000 $0 Begi nni ng 6 months 12 months 18 months 24 months 30 months 36 months 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 housing Sober support network/family Regular meaningful activity Trusting clinical relationship Alverson et al, Com MHJ,

12 Increasing skills and supports leads to recovery Abstinence comes after supports in place Relapse p comes after loss of supports - Alverson et al, Com MHJ, 2000 Principles of Integrated Dual Disorder Treatment Integration of mental health and substance abuse treatment Same team of dually trained people, same location of services, both disorders treated at the same time Stage-wise treatment Different services are effective at different stages of treatment 12

13 Skills for clinicians Knowledge about substances Integrated assessment and treatment planning Stagewise treatment Engagement activities - outreach, support, practical help Persuasion - Motivational counseling, skills training, family and group interventions Active treatment - Substance abuse counseling, skills training, family and group interventions Relapse prevention - Relapse prevention counseling skills training family and group More treatment factors for recovery Training for rehabilitation of skills Social and family support interventions Long term perspective Cultural l Sensitivity and competence Program fidelity 13

14 Transtheoretical Model of Change Prochaska and DiClemente, 1992 HOW PEOPLE CHANGE Maintenance Precontemplation Action Contemplation Preparation/Planning 27 Stages of Change vs. Stages of Treatment Stages of Change: Internal, very fluid Measured by how client is feeling/thinking about change Stages of Tx.: Behavioral, Observable Measured by what client is doing in treatment 14

15 Stages of Treatment Engagement Irregular or no contact with clinician Does not consider substance use or mental illness a problem Corresponds to Precontemplation stage of Change Stages of Treatment Persuasion Regular contact with clinician Does not view substance use or mental illness as problem, but will contemplate impact of substance use on life/goals/values Corresponds to Contemplation stage of Change. 15

16 Stages of Treatment Active Treatment Regular contact with clinician Recognition that substance use or mental illness interferes with personal goals/values Working on acquiring skills and supports to move towards life goals Corresponds to Preparation/Action Stage of Change Stages of Treatment Relapse Prevention No substance abuse for 6 months Furthering recovery to other areas of life Corresponds to Maintenance stage of Change 16

17 Attaining remission occurs in stages Percent Recovered Relapse Prevention Late Active Treatment Early Active Treatment Late Persuasion Early Persuasion Engagement Pre-engagement 0 0 mo. 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Assessment Point Different services are helpful at different stages of treatment Precontemplation - Engagement Outreach, practical help, develop alliance Contemplation Persuasion Motivational Interventions, exploring important goals/values, assessment Active Treatment ID cues/triggers, coping and skills training, self help, groups, family Relapse prevention Update relapse prevention plan, expand recovery to other areas of life 17

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