Co occurring disorders in the criminal justice system. Computerized Assessment and Referral System (CARS) A New Tool for Courts.

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1 Computerized Assessment and Referral System (CARS): A New Tool for Courts Erin Holmes, Director of Traffic Safety TMCEC Municipal Traffic Safety Initiatives Conference Austin, TX; March 29, 2017 Overview Co occurring disorders Prevalence Implications in the CJS Mental health disorders and DUI offending Screening and assessment Processes and instruments Computerized Assessment and Referral System (CARS) Resources 1 Co occurring disorders in the criminal justice system 2 1

2 Co occurring disorders Previously referred to as dual diagnosis co existence of both a substance use disorder and mental health disorder(s). Individuals with mental health disorders are more likely to experience alcohol or drug dependency. Co occurring disorders are often difficult to diagnose as symptoms can be complex and the severity of the disorders can vary. In 2014, approximately 7.9 million adults in the United States had co occurring disorders (SAMHSA, 2015). 3 Treating co occurring disorders System failure: in many cases, people receive treatment for one disorder while the other disorder remains undiagnosed and/or untreated. Consequences: higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or death. Individuals with co occurring disorders are best served through integrated treatment. Address mental health and substance use disorders concurrently. Early detection and treatment improves treatment outcomes. 4 Co occurring disorders in the CJS More than 2/3 of those incarcerated in jail and ½ of prison inmates have a substance use disorder (Karberg and James, 2005; National GAINS Center, 2004). The rates of serious mental illnesses are 4 6x higher in jails and 3 4x higher in prisons than in the general population (Prins, 2014; Steadman et al., 2009). Prison inmates with mental disorders are also more likely to have substance use disorders than inmates without mental disorders (74% vs. 56%) (Mumola and Karberg, 2006). Co occurring disorders are more often the rule than the exception in justice settings (Peters et al., 2015). 5 2

3 Co occurring disorders in the CJS Failure to identify co occurring disorders in the criminal justice system can result in: Increased risk of recidivism Misclassification of risk levels Victimization Lengthier periods of incarceration Inappropriate or inadequate treatment referrals Poor treatment outcomes Missed re entry opportunities Return to the system (Peters et al., 2008) 6 Co occurring disorders among DUI offenders Approximately 25% of individuals arrested and 30% of individuals convicted of DUI are repeat offenders (Warren Kigenyi and Coleman, 2014). This means that contact with the criminal justice system in and of itself, does not deter at least 1/4 of all offenders. While research has shown that impaired drivers frequently have a substance use disorder, many of these offenders also have a psychiatric condition. The presence of a substance use disorder actually increases an individual s likelihood of having other psychiatric disorders. 7 Co occurring disorders among DUI offenders In a study of repeat DUI offenders, it was found that 44% had a lifetime major mental disorder. Another study that examined the prevalence of these disorders by gender found that 50% of female drunk drivers and 33% of male drunk drivers have at least one psychiatric disorder. Mental health issues often linked to impaired drivers include: depression, bipolar disorder, conduct disorder, anxiety, anti social personality disorder, and post traumatic stress disorder (PTSD). 8 3

4 The need for mental health assessment among DUI offenders Very high level of psychiatric co morbidity in DUI populations. Mental health issues linked to recidivism. Treatment has traditionally consisted of alcohol education or interventions that focus solely on alcohol or substance use. Screening or assessment for mental health issues is not always available/performed. DUI treatment providers rarely have the training/experience to identify mental health issues among their clients. Subsequently, in many cases, problems are not identified or addressed. 9 Screening and assessment 10 Screening Screening is the first step in the process of determining whether a DUI offender should be referred for treatment. At this stage, offenders who do not have substance or mental health issues are identified and those who may have issues can be sent for a more in depth assessment. Essentially, screening is a way to strategically target limited resources by separating offenders into different categories (i.e., those who do not have an alcohol/mental health problem and those who likely do). The screening process in and of itself can also serve as a brief intervention as it requires the individual to begin to think about their use patterns and whether they are problematic. 11 4

5 Assessment After the screening process is completed, offenders who show signs of substance or mental health issues can be referred for an assessment. An assessment tends to be more formal than screening and these instruments are standardized, comprehensive, and explore individual issues in depth. In contrast with screening, a formal assessment process takes longer to complete (it can take several hours) and is typically administered by a trained clinician or professional. This second step is meant to evaluate not only the presence of a substance use disorder (alcohol and/or drugs) but its extent and severity. 12 Assessment Ideally, screening and assessment would occur at the beginning of the process (such as during the pre trial stage). The results can then be used to inform: Sentencing decisions; Case management plans; Supervision levels; and, Treatment referrals/plans. It is important to note that assessments can be repeated at multiple junctures throughout an offender s involvement in the criminal justice system to identify progress and to inform changes to existing plans as needed. 13 Common assessment instruments Alcohol Dependence Scale (ADS) Adult Substance Use and Driving Survey Revised(ASUDS R) Alcohol Severity Index (ASI) Alcohol Use Disorder Identification Test (AUDIT) Inventory of Drug Taking Situations (IDTS) Drug Abuse Screening Test (DAST) Level of Service Inventory Revised (LSI R) Michigan Alcoholism Screening Test (MAST) Substance Abuse Subtle Screening Inventory (SASSI) Research Institute on Addiction Self Inventory (RIASI) Risk and Needs Triage (RANT) 14 5

6 Limitations of instruments Majority of instruments are not designed for or validated among a DUI offender population with several exceptions: DUI RANT, Impaired Driving Assessment (IDA), and CARS. Using traditional assessment instruments, DUI offenders are commonly identified as low risk due to a lack of criminogenic factors. DUI offenders often have unique needs and are resistant to change on account of limited insight into their behavior. Several organizations have recognized the need to create assessment instruments specifically for DUI offenders: Responsibility.org, American Probation and Parole Association (APPA), National Center for Drug Court Professionals (NADCP). 15 Development and implementation of CARS 16 The development of CARS CARS was developed by a team of researchers from Cambridge Health Alliance, a teaching affiliate of Harvard Medical School. Initial grant funding was provided by NIAAA; Responsibility.org continues to fund CARS research and implementation. The goal was to create an assessment tool specifically for a DUI offender population that fills the mental health void that exists with traditional instruments. 17 6

7 The development of CARS CARS is a standardized mental health assessment that is adapted from the World Health Organization s Composite International Diagnostic Interview (CIDI). Developed by Dr. Ron Kessler and his team at Harvard, the CIDI is a structured interview for psychiatric disorders. Internationally validated instrument Used extensively in research including the National Comorbidity Survey 18 Purpose of CARS CARS is a risk and needs assessment. High Risk/ High Need High Risk/ Low Need Low Risk/ High Need Low Risk/ Low Need Primary purpose: identify mental health and substance use disorders among DUI offenders and facilitate treatment referral for those issues. Secondary use: predict DUI recidivism risk from mental health profiles

8 What is CARS? Diagnostic report generator Case management Mental health assessment Brief intervention Referral database 21 What is CARS? Diagnostic report generator that gives providers and clients: Immediate diagnostic information for up to 20 DSM IV Axis I disorders (onset, recency, persistence). Geographically and individually targeted referrals to treatment services based on the outcomes of the assessment. Substance dependencecars Mental health issues Intervention 22 How does CARS work? The CARS tool is a completely electronic assessment tool. It is available as free open source software. There are three versions of the CARS tool that can be used: Full assessment Screener Self administered screener CARS is divided into modules representing various mental disorders and psychosocial factors. The individual administering CARS can select any subset of modules. There is the ability to choose from a past 12 month or lifetime version of the questions for each disorder. 23 8

9 CARS comprehensive mental health screener domains Panic disorder Social phobia Eating disorders Intermittent explosive disorder Attention deficit/hyperactivity disorder Obsessive compulsive disorder Depression Generalized anxiety Suicidality Mania/bipolar disorder Post traumatic stress disorder Conduct disorder Oppositional defiant disorder Psychosis Nicotine dependence Alcohol use disorder Drug use disorder Gambling disorder Psychosocial stressors DUI/criminal behavior 24 How does CARS work? 25 How does CARS work? 26 9

10 How does CARS work? Individual diagnostic reports have been programmed to provide information about the mental health disorders for which a person qualifies or is at risk, as well as a summary of bio psycho social risk factors. The CARS tool includes a section on DUI behavior. The data obtained from the questions in this section is integrated with other risk factors to generate an overall DUI recidivism risk score. A graphic is generated as part of the outcomes report that indicates where an individual is within a range of low to very high risk. 27 CARS report 28 Taking it one step further Unlike traditional assessments, CARS has a built in referral system. CARS has been designed to include a list of individually targeted referrals at the end of each report based on an individual s issues and zip code. The services can include hospitals, outpatient treatment programs, detox programs, halfway houses, self help programs, etc. Also included are public transportation options (such as bus routes) to travel to each location. Before CARS can be implemented, the referral list must be populated with treatment services that are available within that jurisdiction

11 Taking it one step further 30 Implementation study The usability of CARS was previously tested; feedback led to the creation of the enhanced screener module. In 2015, a randomized control trial was completed in two Massachusetts DUI programs. The purpose of this study was to determine: How does the screener perform in comparison to the full CARS assessment? Are the CARS screener and full CARS valid assessment instruments? Can the CARS screener be successfully self administered? Does engaging with CARS increase later treatment retention and improve outcomes? How do specific psychiatric disorders relate to recidivism? 31 Implementation study The study found that a positive screen indicates that further assessment is required, not that the respondent qualifies for the disorder and that the completion of full CARS provides diagnostic information. Results from the self administered version of the screener do not differ fundamentally from those for the intervieweradministered screener although the self administered version may be more sensitive for some disorders. The study also revealed evidence of comorbidity in the repeat DUI offender population, particularly anxiety related disorders

12 2016 Pilot Sites CARS was implemented within several programs to identify best practices for implementation and use. Six jurisdictions: Stockton, California Laramie County, Wyoming Isanti County, Minnesota Duluth, Minnesota Milwaukee, Wisconsin Lackawanna County, Pennsylvania All three versions of the tool being incorporated in different programs, at various points within the judicial process Pilot Sites: Administration 34 Recommendations Increase the specificity of the CARS screener. Improve targeted referrals. Develop a version of full CARS that contains only past year modules. Create separate screener and full assessment executables for download. Create explicit and detailed instructions for installing/updating CARS software. Develop different levels of training for practitioners based on level of experience; consider interactive online training

13 Recommendations In response to the main CARS concern, new interference matrices have been added to the screener to increase specificity. 36 Future considerations Develop a Spanish version of CARS. Develop a non DUI specific version of CARS. Update CARS to reflect DSM V changes. Consider developing a web based platform instead of utilizing software. Create a CARS mobile application. 37 Benefits of CARS Provides immediate diagnostic information for up to 20 major psychiatric disorders. Provides geographically and individually targeted referrals to appropriate treatment services. Generates user friendly reports at the click of a button. Informs supervision and treatment decisions. Runs on free open source software. Can be used by non clinicians. Applicable in a number of settings

14 National roll out CARS will be launched for general use in May/June Available to any court, probation department, or program free of cost. Online web portal for downloads and training. 39 Computerized Assessment and Referral System (CARS) 40 CARS and the ER Partnering with the Emergency Medicine Foundation to pilot CARS in several emergency departments/systems throughout the country. EDs can serve as a point of identification and intervention for alcohol misuse. Opportunity to test CARS among a more general population; expands usability beyond the criminal justice system. Pilot locations to be determined early

15 Help us guide a lifetime of conversations responsibility.org and #responsibility 42 15

16 Client Session:2010, Jane, Sep 26, 2014, Division on Addiction CARS Diagnostic Report Prepared for: Division on Addiction TABLE OF CONTENTS CARS Diagnostic Case Summary DUI Report Detailed Diagnostic Reports Alcohol Abuse Alcohol Dependence Personality Disorders Risk Profile Assessments Regional Referral Information CARS is a screening device and it does not provide a final diagnostic determination. Further evaluation is necessary to determine whether problems reported are sufficient to qualify as a disorder and to determine the level of problem severity.

17 Client: Jane Gender: Female Age: 35 CARS Assessment Progress This graphic represents how much of the CARS assessment Jane has completed. Alcohol Use Personality Disorders Driving under the influence Enhanced Screener 2

18 Client: Jane CARS Diagnostic Case Summary Gender: Female Age: 35 Jane is a 35 year-old White woman. She has screened positive for 2 co-occurring mental health problems (see Table 1) and should receive a referral for professional mental health assessment (regional referrals are listed on the end of the report). Jane has accumulated 2 DUI arrests during her lifetime. Table 1. Mental Health Profile Met Criteria Subclinical Symptoms Screened into but not tested Alcohol Abuse Alcohol Dependence Personality Disorder PY PY Based on Jane's answers, she might be suffering from a personality disorder. Please refer to the personality disorder detailed report. PY = Past Year, LT = Lifetime *Other disorders screened:ptsd, Substance Abuse, Substance Dependence, Major Depressive Disorder, Bipolar I, Bipolar II, Bipolar NOS, Dysthymia, Panic Disorder, Social Phobia, Intermittent Explosive Disorder, Tobacco Use, Gambling, Eating Disorders, Obsessive Compulsive Disorder, Psychosis, ADHD, Conduct Disorder, Oppositional Defiant Disorder, GAD DUI Recidivism Risk Factors Jane is at extremely high risk for another DUI. Listed below are some of the factors that create this risk for Jane. Jane reported that she has been arrested for DUI. Other risk factors include: Alcohol use disorder Antisocial personality disorder Endorsed binge drinking Insufficiently prepared to change DUI behavior High BAC at arrest Early initiation of regular drinking Previous DUI accident Risky Driving Behaviors Based on Jane s mental health profile, she should consider seeking additional professional screening from the resources listed at the end of the report. 3

19 Client: Jane Gender: Female Age: 35 Suicide Risk Factors Jane reported that she has seriously considered comitting suicide. 4

20 Client: Jane Gender: Female Detailed DUI Report Age: 35 Jane reported driving while intoxicated or while under the influence of illicit or mind-altering substances in the past 12 months. She reported having been pulled over or arrested for driving under the influence in the past 12 months. She reported having been arrested in the past 12 months. She reported never having been incarcerated. DUI Behavior Behavior Lifetime Frequency Age of Onset Past 30 day Frequency Frequency since most recent DUI Been asked to take a breathalyzer test after being pulled over for Twice n/a n/a n/a DUI Taken a breathalyzer test after being pulled over for DUI Twice n/a n/a n/a Been arrested for driving under the influence (even if not found Twice 22 n/a n/a guilty) Been convicted of driving under the influence Twice n/a n/a n/a Been pulled over for driving under the influence Three times n/a n/a None Gotten into an accident while driving after drinking any alcohol Once n/a n/a n/a Gotten into an accident while driving intoxicated or under the Once n/a n/a n/a influence of an illicit substance Had your license revoked or suspended due to DUI Once n/a n/a n/a Driven while under the influence of an illicit substance Never n/a n/a n/a Ridden with an intoxicated or impaired driver Never n/a n/a n/a Driven while intoxicated or impaired with passengers in the car Never n/a n/a n/a Driven while intoxicated or impaired with minors in the car Never n/a n/a n/a Attempted to avoid a sobriety checkpoint Never n/a n/a n/a Driven while your license was suspended or revoked due to DUI Never n/a None None Had an ignition interlock on your car due to DUI Never n/a n/a n/a Had your car impounded due to DUI Never n/a n/a n/a Driven after drinking any alcohol More than 5 18 None None Driven while intoxicated More than 5 18 n/a None Highest BAC ever recorded: 0.20 or greater Circumstances of first arrest for DUI: I sped and ran a red light and got pulled over. Circumstances of most recent arrest for DUI: I was weaving in and out of the traffic lanes and got pulled over. 5

21 Client: Jane Gender: Female Age: 35 Jane's most recent DUI arrest occured between 7 and 12 months ago. Her license was suspended after her most recent DUI and is still suspended. An ignition interlock was not installed on her vehicle. Reason for driving after drinking before most recent DUI I had to get home. It was getting late. Reason for drinking before most recent DUI arrest Because I was stressed. Reason for driving after drinking before most recent DUI Because I had to get home somehow, and I couldn't get a ride. DUI Treatment and Treatment Readiness Current Program: Second / repeat offender program inpatient (e.g., Middlesex DUIL) Past and current DUI treatment # of times entered # of times completed Currently attending First Year attended DUI first offender program (e.g., Driver Alcohol Education) DUI second / repeat offender program - inpatient (e.g., Middlesex DUIL) DUI second / multiple offender program - outpatient or aftercare DUI Court 1 1 N N 2014 n/a n/a N n/a n/a n/a N n/a DUI-Related Drinking Other DUI Program n/a n/a N n/a Jane drank nearly every day, consuming an average of 5 drinks per drinking day within the month prior to her arrest. Jane's last drink was prior to last DUI arrest. Drinking Motives Behavior To forget your worries Because it helps you when you feel depressed or nervous To forget about your problems To cheer you up when you are in a bad mood To fit in with a group you like To be liked So you won't feel left out Frequency Rarely Rarely Rarely Rarely 6

22 Client: Jane Coping Motivation Score: 7/12 Conformity Motivation Score: 3/12 Gender: Female Age: 35 Drinking Context Drinking Settings At parties At restaurants At bars Alone At home Frequency Often Often Often Often In other public locations (e.g, outside, in parks, at schools, on public transportation) In your car With people you don't know well With work colleagues At work Rarely Modes of Transportation after Drinking Drive yourself home Get a ride from someone who has also been drinking Get a ride from someone who is sober or call a taxi Stay at the place where you were drinking Frequency Rarely Social Network Peer Behaviors Get drunk often Drink with you on a regular basis Do drugs other than alcohol Have been in trouble with the law Are abstinent % of Peers who Engage in Behavior 50% (Half) 50% (Half) 50% (Half) 50% (Half) 0% (None) Criminal Behavior Criminal History Lifetime Frequency Age of first occurence Most recent occurence Been arrested for something other than DUI Never 7

23 Client: Jane Gender: Female Age: 35 Been incarcerated Been on parole Been on probation Violated your parole or probation Had a restraining order against you Never Never Never Never Never Circumstances of most recent non-dui arrest: N/A Risky Driving Behavior Been pulled over by police Gotten into a verbal altercation with someone in another car while driving or as the immediate result of a driving incident Been involved in an accident Gotten into a physical altercation with someone in another car while driving or as the immediate result of a driving incident Behavior Drive more than 10 mph over the speed limit Drive through a red light Verbally insult or make rude gestures at other drivers Weave in and out of slower traffic Tailgate other drivers Illegally pass a vehicle if it is moving too slowly Lose your temper while driving Text while driving Drive when you are overly tired Find yourself crossing lane lines or swerving because you were distracted or tired Lifetime Frequency Twice Once Once Never Frequency Risky Driving Score: 20/57 8

24 Client: Jane Gender: Female Age: 35 Assessment for Alcohol Abuse Disorder When people experience a pattern of drinking alcohol that leads to distress, health problems, or affects their ability to function, they might have alcohol abuse. Abusing alcohol can cause problems at work, school, or home. They might have unplanned absences. They might not complete their work. They might neglect responsibilities. People with alcohol abuse might use alcohol in dangerous situations, like driving a car or using heavy machinery. Because of their drinking, some people even have trouble with the law. Drinking might cause them to have arguments or fights with others. When a person continues to use alcohol despite these difficulties in daily life, but does not meet criteria for alcohol dependence, clinicians can diagnose them as having alcohol abuse. Diagnosis Jane s responses to the CARS assessment suggest that she might meet criteria for current alcohol abuse. The current experience of alcohol abuse could impair Jane s DUI re-offense prevention plan. Those who suffer from alcohol abuse have an elevated risk for DUI re-offense. The regional referral information at the end of the report provides information for additional mental health screening and treatment that could help with Jane s alcohol abuse symptoms and could reduce the likelihood of DUI re-offense. Detailed Symptoms Past Year Jane reported one symptom of alcohol abuse in the past 12 months. Specifically, she reported that: she was arrested or stopped by the police in the past 12 months because of drunk driving or drunken behavior Quit Attempts Jane reported that she made a serious attempt to quit drinking in the past 12 months. Disorder History Age at first episode of symptoms: 22 Most recent episode of symptoms: Years with continuing symptoms: 2 Treatment History More than 6 months ago Jane reported 2 close relatives who also had problems with alcohol use. 9

25 Client: Jane Gender: Female Age: 35 Assessment for Alcohol Dependence Disorder When people continue using alcohol even though it causes problems, they might be alcohol dependent. They might need to drink more and more alcohol to get the same effect. Smaller amounts of alcohol might not feel like enough. When they try to stop or cut down their alcohol use, they might experience some distressing or even life-threatening withdrawal symptoms. This withdrawal syndrome can include shakiness; sweating; racing heartbeat; nausea or vomiting; anxiety; high blood pressure; seizures; hallucinations; or confusion. People with alcohol dependence might spend a great deal of their time and energy trying to obtain alcohol. People with alcohol dependence often find that they cannot stop drinking even though they know it is harming them. When their pattern of drinking affects their ability to function in day-to-day life, clinicians can diagnose them as having an alcohol dependence disorder. Diagnosis Jane s responses to the CARS assessment suggest that she might meet criteria for current alcohol dependence. The current experience of alcohol dependence could impair Jane s DUI re-offense prevention plan. Those who suffer from alcohol dependence have an elevated risk for DUI re-offense. The regional referral information at the end of the report provides information for additional mental health screening and treatment that could help with Jane s alcohol dependence symptoms and could reduce the likelihood of DUI re-offense. Detailed Symptoms Past Year Jane reported multiple symptoms of alcohol dependence in the past 12 months. Specifically, she reported that: she needed to drink a larger amount of alcohol to get an effect or could not longer get a "buzz" on the amount she used to drink she drank a lot more than intended or started drinking even though she promised herself she wouldn't she had times when she took a drink to keep from having problems like these she drank more frequently or for more days in a row than she intended she had times when she started drinking and became drunk when she didn t want to she continued to drink when she knew she had a serious physical or emotional problem that might have been caused by or made worse by drinking 10

26 Client: Jane Gender: Female Age: 35 Quit Attempts Jane reported that she made a serious attempt to quit drinking in the past 12 months. Disorder History Age at first episode of symptoms: 22 Most recent episode of symptoms: Years with continuing symptoms: 2 More than 6 months ago Age at first episode of 3 or more symptoms in a 12-month period: Most recent episode of 3 or more symptoms in a 12-month period: 22 More than 6 months ago Years with 3 or more continuing symptoms in a 12-month period: Treatment History Jane reported 2 close relatives who also had problems with alcohol use. 2 11

27 Client: Jane Gender: Female Age: 35 Assessment for Personality Disorders People with personality disorders (PD) have unhealthy patterns of thought and behavior and often experience problems with emotions and relationships. These patterns of behavior disrupt their personal and social life. There are three main groups of PD, called clusters. Cluster A: Cluster A includes odd and paranoid thinking and behavior. Cluster B: Cluster B (Antisocial) includes dramatic, risky, or very emotional thinking and behavior. In this report Cluster B disorders are divided into antisocial personality disorder and borderline personality disorder. Cluster C: Cluster C includes anxious, needy, or fearful thoughts and behavior. This screen does not provide a definitive personality disorder diagnosis. Instead, the screen is intended simply to separate those people who are definitely unlikely to have a particular personality disorder from those people who might possibly have a particular personality disorder. Many people who are identified as possibly having a particular personality disorder using this screening device will never be diagnosed with that disorder. Only an experienced clinician can make a diagnosis. Clients who screen positive for a personality disorder should consider seeking additional professional screening from the resources listed at the end of the report. Probable Possible No Case Cluster A Cluster B:Antisocial Cluster B:Borderline Cluster C Antisocial Personality Disorder (Cluster B Personality Disorder) Jane reported clinically-significant experiences that suggest the possible presence of antisocial personality disorder. Borderline Personality Disorder (Cluster B Personality Disorder) Jane reported clinically-significant experiences that suggest the probable presence of borderline personality disorder. 12

28 Client: Jane Gender: Female Detailed Risk Assessment Age: 35 Biopsychosocial Risk Assessment Jane's legal history also increases risk for more DUI offenses as she reports: having driven while intoxicated having been pulled over or arrested for driving under the influence having been arrested There are a number of biopsychosocial factors that relate both to poor mental health and to risk for DUI recidivism. Notably, Jane has reported a family history of other mental health problems. Specifically Jane's family members may have symptoms of: Alcohol use She has mentioned some important psychosocial factors that should influence treatment planning and referral. These psychosocial factors include: (During the past 12 months) Illness or injury of a family member, friend, significant other, or loved one Difficult changes in her living situation Feelings of social isolation or loneliness Stress about finances DUI Recidivism Risk Assessment Anyone who drinks and drives is at risk for committing a DUI offense. Having a history of DUI offense also puts Jane at risk for more DUI offenses. Individuals who experience problems with mental health, like depression and anxiety, have a criminal history, report other traffic violations, or who often engage in risky patterns of drinking and/or driving, such as binge drinking or driving recklessly are also at risk for repeating DUI offense. Based on Jane's reported history, she is at extremely high risk for additional DUI offenses. 13

29 Client: Jane Gender: Female Age: 35 14

30 Client: Jane Gender: Female Regional Referral Information Age: 35 Based on Jane's interview and the zip code provided (02139), referrals to the 5 closest Massachusetts resources for additional mental health screening and treatment are listed below. In addition to these options, Jane also might consider utilizing other relapse and recovery resources, such as Alcoholics Anonymous or online recovery and recidivism prevention programs. Prevention and Recovery Center 330 Mount Auburn St, Cambridge, MA (617) x Type of Care: Outpatient Payment Options: Accepts most types of insurance, and private pay Insurance: Cigna Medicare/Medicaid: Yes Specializations: not specified Public Transportation Options: MBTA Bus 71/73 - Mt Auburn Longfellow Rd Cambridge Health Alliance 1493 Cambridge St, Cambridge, MA (617) Type of Care: Inpatient and outpatient Payment Options: Acepts most, including MassHealth, and help patients with financial assistance and finding insurance Insurance: unknown Medicare/Medicaid: Yes Specializations: Family/couples; anxiety, depression, chronic or acute mental illness; geriatric; DBT; addiction; separate programs for Asian/Latino/Hispanic/Portuguese patients Public Transportation Options: MBTA Bus 69- Cambridge St & Highland Ave MBTA Bus 83/91- Hampshire St & Cambridge St Womanplace 11 Russell St, Cambridge, MA (617) Type of Care: Residential Payment Options: Accepts most types of insurance, and private pay; accepts many uninsured clients Insurance: unknown Medicare/Medicaid: Yes Specializations: Substance use; HIV/AIDS; pregnant/postpartum clients Public Transportation Options: MBTA Bus 77/83 - Massachusetts Ave opp Walden St MBTA Bus 87/96 - Elm Cutter Ave 15

31 Client: Jane Gender: Female Age: 35 MAPS DAE 1046 Cambridge St, Cambridge, MA (617) Type of Care: Outpatient Payment Options: Accepts only Mass Health. Does not accept private pay. Insurance: unknown Medicare/Medicaid: Yes Specializations: not specified Public Transportation Options: MBTA Bus 85/CT2 - Columbia Cambridge St MBTA Bus 69 - Cambridge Norfolk St. North Charles Institute for the Addictions 260 Beacon St, Somerville, MA (617) Type of Care: Outpatient Payment Options: unknown Insurance: unknown Medicare/Medicaid: unknown Specializations: not specified Public Transportation Options: MBTA Bus 8/10 - Southampton Atkinson St. MBTA Fairmount Line - Newmarket Targeted Referrals Prevention and Recovery Center 330 Mount Auburn St, Cambridge, MA (617) x Type of Care: Outpatient Payment Options: Accepts most types of insurance, and private pay Insurance: Cigna Medicare/Medicaid: Yes Specializations: not specified Public Transportation Options: MBTA Bus 71/73 - Mt Auburn Longfellow Rd 16

32 Client: Jane Gender: Female Age: 35 Womanplace 11 Russell St, Cambridge, MA (617) Type of Care: Residential Payment Options: Accepts most types of insurance, and private pay; accepts many uninsured clients Insurance: unknown Medicare/Medicaid: Yes Specializations: Substance use; HIV/AIDS; pregnant/postpartum clients Public Transportation Options: MBTA Bus 77/83 - Massachusetts Ave opp Walden St MBTA Bus 87/96 - Elm Cutter Ave Riverside Outpatient Center at Mystic 35 A Memorial Road, Somerville, MA (781) Type of Care: Outpatient Payment Options: Accepts most types of insurance, and private pay Insurance: unknown Medicare/Medicaid: Yes Specializations: General behavioral health Public Transportation Options: MBTA Bus 95 - Mystic Temple Rd MBTA Bus 89/93/101/ Broadway opp. Temple St Alcohol and Drug Education/Youth Assistance 226 Highland Ave, Somerville, MA (617) Type of Care: Residential Payment Options: Does not accept insurance Insurance: unknown Medicare/Medicaid: No Specializations: not specified Public Transportation Options: MBTA Bus 88/90 - Highland Tower St 17

33 Client: Jane Gender: Female Age: 35 Cambridge Health Alliance Adult Psychiatry 26 Central St, Somerville, MA (617) Type of Care: Outpatient Payment Options: Accepts most types of insurance and private pay Insurance: unknown Medicare/Medicaid: Yes Specializations: Anger, anxiety, drugs, stress, relationships, fears, depression, mood, personality, and women's issues Public Transportation Options: MBTA Bus 87/96 - Elm St. James Ave. MBTA Bus 88/90 - Highland Willow Ave. Emergency Departments In case of life-threatening emergency dial 911 Stillman Infirmary Harvard University 75 Mount Auburn Street, Cambridge, MA (617) Public Transportation Options: MBTA T Red Line- Harvard Square MBTA Bus Route 71/72/73/74/75/77/78/86/96 - Harvard Square Station MBTA Bus Route 1/68/69 - Massachusetts Holyoke Gate MBTA Bus Route 66 - Eliot Bennett St Youville Hospital and Rehabilitation Hospital 1575 Cambridge Street, Cambridge, MA (617) Public Transportation Options: MBTA Bus Route 69 - Cambridge Hovey Ave MBTA Bus Route 68 - Ellery St MBTA Bus Route 72 - Cambridge St & Prescott St MBTA Bus Route 86 - Kirkland St opp Trowbridge St MBTA Bus Route 83 - Beacon Smith Ave MBTA Bus Route 1 - Massachusetts Holyoke Gate MBTA T Red Line - Harvard Square MBTA Bus Route 71/73/74/75/77/78/96 - Harvard Square Station Cambridge Hospital Cambridge Health Alliance 1493 Cambridge St, Cambridge, MA (617) Public Transportation Options: MBTA Bus Route 69 - Cambridge Highland Ave MBTA Bus Route 83/91 - Hampshire Cambridge St MBTA Bus Route 68 - Crawford St MBTA Bus Route 86 - Washington Beacon St MBTA Bus Route 1 - Massachusetts Hancock St 18

34 Cambridge Health Alliance Division on Addiction HARVARD MEDICAL SCHOOL TEACHING AFFILIATE What Is CARS? CARS (i.e., the Computerized Assessment and Referral System) is a computerized clinical report generator tool that incorporates a structured diagnostic mental health assessment. Comprehensive clinical assessment tools can provide volumes of high quality diagnostic information that facilitate effective treatment planning, but commonly are not user-friendly. CARS packages a powerful mental health assessment tool with a user-friendly interface, increased flexibility, and immediate personalized output, to create a tool that laypeople can use easily to administer comprehensive mental health assessments. CARS output includes personalized information about the mental health disorders for which a client qualifies or is at risk, a summary of other risk factors and important issues, and a list of resources targeted by a client s issues and location. We created a pilot version of CARS to facilitate the NIAAA-funded study, Toward Evidence Based Treatments to Reduce DUI Relapse (1 R01 AA A1). In partnership with the Foundation for Advancing Alcohol Responsibility (FAAR), a nonprofit organization with a focus on preventing DUI, we have refined and expanded CARS, and tested its usability within multiple Massachusetts DUI treatment settings. Within the next two years, we will: (1) finish modifying CARS based on user feedback, adding self-administered and enhanced stand-alone screener modules; (2) implement CARS fully at two Massachusetts DUI offender treatment sites; and (3) evaluate the usability of CARS among programs and clients, and the efficacy of CARS as a brief intervention by tracking client outcomes across time. Why Do People and Programs Need CARS? Mental health problems that extend beyond substance use disorders are common among people with addiction, and can affect treatment outcomes. Yet, in a variety of clinical settings (e.g., addiction treatment facilities or DUI offender programs; see Shaffer et al., 2007), clients often do not undergo comprehensive screening for psychiatric disorders. Even when treatment programs attempt to estimate the extent of psychiatric disorders, in the absence of systematic screening tools, those efforts often are inaccurate. Research has shown that health care providers make errors when identifying mental health problems, especially when those problems are not in their area of expertise. Staff at community treatment programs for DUI populations often has little expertise in mental health issues. Consequently, standardized and automated assessment and diagnosis tools are essential to the widespread adoption of mental health screening. Because CARS uses the internationally-recognized CIDI (i.e., Comprehensive International Diagnostic Interview), the included assessments are well-validated and reliable. One problem with standardized assessment tools that contributes to resistance is that many such tools are used only for research purposes and provide no immediate output for counselors or clients during a clinical session. If a tool can supply immediate assessment or diagnostic feedback, it can serve to increase compliance and improve treatment because counselors will be able to reap the benefits of using the instrument. CARS provides immediate personalized output that counselors can use to inform treatment for individual clients. The reports CARS generates assist staff by providing personalized information about disorders and possible referral sources for their clients. 1

35 Cambridge Health Alliance Division on Addiction HARVARD MEDICAL SCHOOL TEACHING AFFILIATE How Is CARS Being Developed and Tested? CARS adapts a pre-existing standardized mental health assessment, the Composite International Diagnostic Instrument (CIDI). The computerized version of the CIDI includes 41 modules: 21 that inform DSM-IV Axis I diagnoses and 20 that collect information about other demographic and psychosocial variables. Through the 21 diagnostic modules, the CIDI measures the presence, age of onset, and remission of drug and alcohol dependence or abuse and other psychiatric disorders (e.g., depression, PTSD). We have collaborated with one of the founders of the CIDI, Dr. Ron Kessler and his team at the Harvard School of Public Health, to modify the CIDI for CARS. CARS also takes advantage of open source software (i.e., Java, Drools, and MySQL), reducing costs to potential users, and includes a report generator to provide both diagnostic information and summary risks, as well as a zip code-based resource database for Massachusetts. To test the usability of CARS, we recruited a sample of 5 agencies working with DUI offenders. We asked the users to utilize CARS, as prescribed in their utilization plan, for three months. Throughout that three-month period, users completed online surveys about their experiences with CARS that assessed the tool s usability, time requirement, typical use and referral system. Based on the results of this study and input from key stakeholders, we are currently modifying CARS. In particular, we are creating an empirically-based screener module that can be used on its own in settings where less than a half hour is available for assessment, and we are developing a self-administered version of that screener. We are now in the process of recruiting two programs to participate in a full implementation trial of CARS as part of their procedures. For six months, within each program, we will randomize implementation, so that equal numbers of clients receive treatment as usual and each of three CARS conditions (i.e., full assessment, screener only, and self-administered screener). Clients who receive CARS will complete the assessment in place of a usual intake. Those who do not receive CARS will receive treatment / assessment as usual. We will re-assess all clients six months after their initial participation, collecting information about their treatment progress, drinking behavior, driving behavior, and legal involvement since they first entered the study. What Are the Long-Term Prospects for Using CARS? There are many options for the future growth of this initiative. We envision building a national Center dedicated to research focused on driving and substance misuse. We hope that this center will emerge from a network of DUI treatment facilities and professionals who utilize CARS and provide input on its expansion, thereby serving as a foundation for DUI related research. Research continues to find strong links between public health concerns such as substance use, DUI, criminal behavior, and homelessness, and underlying mental health issues. As this research increases, so will the desire of programs that address these behavioral problems to assess and address the underlying mental health issues that influence them. CARS can be adapted for use in many kinds of community programs, as well as educational and primary care settings. References Shaffer, H. J., Nelson, S. E., LaPlante, D. A., LaBrie, R. A., Albanese, M. J., & Caro, G. (2007). The epidemiology of psychiatric disorders among repeat DUI offenders accepting a treatment sentencing option Journal of Consulting and Clinical Psychology, 75(5),

36 Revolutionizing DUI Assessment Computerized Assessment and Referral System (CARS) What is CARS? CARS is a report generator that provides immediate diagnostic information for up to 15 major psychiatric disorders (e.g., depression, anxiety disorder, posttraumatic stress disorder, bipolar disorder). CARS is designed to identify mental health concerns in addition to substance use disorders that influence DUI behavior. CARS provides referrals to treatment services based on an individual s diagnostic information and ZIP code. CARS is adapted from the World Health Organization s Composite International Diagnostic Interview (CIDI), an internationally validated assessment. 1 Repeat drunk drivers comprise, on average, 25% of the impaired driving population. 2 People who have been convicted of DUI represent a population with an extremely high rate of substance use disorders % 45 % Research has found that 45% of repeat drunk drivers have a major mental health disorder in addition to alcohol or drug-related disorders. 5 Screening for mental health issues beyond alcohol use disorders is rare within DUI treatment programs. 7 DUI offenders who suffer from psychiatric disorders other than alcohol or drug use disorders re-offend more, and more quickly, than others. 6

37 How CARS works Asks about signs and symptoms of mental health issues both within the past year and lifetime. Identifies specific mental health disorders for which an offender is at-risk. Generates a report that informs the user about a client s treatment needs and provides appropriate referrals. Can be used in three formats: MINUTES MINUTES 1-2 HOURS SELF-ADMINISTERED FULL CARS SCREENER CARS SCREENER CARS ASSESSMENT Benefits of CARS Current efficacy study u Developed specifically for a DUI offender population u Informs supervision and treatment decisions u Provides immediate personalized output and referrals u User-friendly reports at the click of a button u Runs on free open source software u Can be used by non-clinicians u Applicable in a number of settings u Randomized control trials at two Massachusetts DUI treatment programs u Six month follow-up Study will: u Evaluate full implementation of CARS u Test the validity of the CARS screener u Determine whether the CARS screener can be self-administered u Investigate use of CARS as a brief intervention u Examine associations between psychiatric co-morbidity and outcomes among DUI offenders u Preliminary results in 2015 Footnotes 1: 2: 3: 4: 5: 6: 7: For further information please contact: erin.holmes@responsibility.org or visit Responsibility.org/CARS