Integrating Substance Abuse and Mental Health Services for Individuals with Co-occurring Disorders

1
Integrating Substance Abuse and Mental Health
Services for Individuals with Co-occurring
Disorders
Christine Grella, Ph.D. UCLA Integrated Substance
Abuse Programs Delivery Systems for Substance
Abuse Treatment Istanbul, Turkey September 5,
2005
Funded by NIDA-R01-DA11966
2
Overview

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

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Persons with Alcohol, Drug Abuse, or Mental
Disorder in the Past YearU.S. Population, Age 15
to 54, 1991
Source Kessler et al., 1994.
4
Receipt of and Unmet Need for AOD and MH Services
Among Adults with COD
Perceived Unmet Need Among Untreated Adults
Services Received
Source SAMHSA 2002 National Survey on Drug Use
and Health
5
Individuals with COD Have Higher Rates of
Treatment Utilization and Poorer Treatment
Outcomes

• Psychiatric symptoms
• Hospitalization
• Relapse to substance use
• Housing stability
• Psychosocial functioning
• Arrest and incarceration

6
Individuals with COD Seek Treatment in Both AOD
and MH Programs

• Over half of AOD outpatients had probable MH
  disorder (Watkins et al., 2004)
• Clients with COD in AOD and MH settings showed
  minimal differences in severity and type of
  disorders (Havassy, Alvidrez, Owen, 2004)
• National data in U.S. show that 30 of
  individuals with AOD disorders either used or
  perceived an unmet need for MH services in past
  year (Mojtabai, 2005)

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Services for COD in AOD Programs

• Little increase in comprehensive services in
  outpatient drug treatment, 1990-2000
  (Friedmann et al., 2003)
• About half of AOD programs provided services for
  COD in national surveys, 1997-2002
  (McFarland Gabriel, 2004 Mojtabai, 2004)
• Over half of private AOD providers out-refer
  clients with COD rather than treat on-site,
  1995-2001 (Knudsen, Roman, Ducharme, 2004)

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Substance Abuse Treatment Facilities Offering
Special Programs for Clients with COD,1999-20021
1Survey reference dates were October 1 for 1999
and 2000 and March 29, 2002. Source Office of
Applied Studies, Substance Abuse and Mental
Health Services Administration, UFDS Survey,
19961999 National Survey of Substance Abuse
Treatment Services (N-SSATS), 2000 and 2002.
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Approaches to Services Integration

• Incorporate MH services into AOD treatment
  programs
• assessment and diagnosis
• pharmacotherapy, med management
• psychotherapy
• Incorporate AOD services into MH programs
• psychoeducation
• contingency management
• motivational interviewing
• relapse prevention
• 12-step groups
• Develop specialized programs for COD that are
  fully integrated

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Four-Quadrant Framework for COD
High severity
More severemental disorder/more severe
substanceabuse disorder
Less severemental disorder/more severe
substanceabuse disorder
Less severemental disorder/less severe
substanceabuse disorder
More severemental disorder/less severe
substanceabuse disorder
High severity
Lowseverity

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

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Service Delivery for COD
Source Ries, 2004
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National Treatment Plan Initiative - No Wrong
Door Approach
ACCESS AND INTER-SYSTEM LINKAGES Develop a plan
to create a nationwide expectation for alcohol
and drug treatment such that no matter where in
the human services, health, or justice system an
individual appears, his or her alcohol or drug
problem will be appropriately identified,
assessed, referred, or treated.
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No Wrong Door to Treatment

• Assessment, referral, and treatment planning for
  all settings must be consistent with a no wrong
  door policy.
• Creative outreach strategies may be needed to
  encourage some people to engage in treatment.
• Programs and staff may need to change
  expectations and program requirements to engage
  reluctant and unmotivated clients.
• Treatment plans should be based on clients needs
  and should respond to changes as they progress
  through stages of treatment.
• The overall system of care needs to be seamless,
  providing continuity of care across service
  systems. This can only be achieved through an
  established pattern of interagency cooperation or
  a clear willingness to attain that cooperation.

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REPORT TO CONGRESS ON THE PREVENTION AND
TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE
AND MENTAL DISORDERS U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES Substance Abuse and Mental
Health Services Administration 2002
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Levels of Program Capacity in Co-Occurring
Disorders
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Treatment Guidelines for COD are Emergent, but
Lack Consensus

• Empirical evidence is lacking for most
  recommendations, particularly regarding
• need to treat patients in integrated settings
• sequencing of AOD and MH treatment
• Integrated treatment is variously defined
• unified treatment program, staff, approach
• co-location of services at primary site
• system-level linkages and referrals
• Recommendations tend to be broad, rather than
  diagnosis- or setting-specific
• Source Watkins et al., 2005

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UCLA Dual Diagnosis Study Project Aims

• To assess AOD and MH programs with regard to
  service delivery and treatment approaches for COD
• To compare differences in attitudes, beliefs, and
  perceptions between administrators and staff in
  AOD and MH programs
• To evaluate outcomes of clients with COD who are
  treated in AOD programs that vary in services
  integration

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Services for COD in Los Angeles County

• AOD and MH treatment in Los Angeles County have
  been provided in separate and divergent service
  systems
• Countywide initiatives have aimed to improve
  coordination and collaboration across the 2
  systems
• Partnerships have been developed between AOD and
  MH providers in the same area, with varying
  degrees of service integration

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Service Delivery for COD in Los Angeles County
DHS
ADPA
DMH
Administrators
Administrators
Services Coordination/ Collaboration
MH Programs
AOD Programs
Staff
Staff
Study entry
Clients
Families
CJS
Housing
Health
Welfare
Community Stakeholders
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Methods

• Interviews and surveys were conducted with
  administrators of 16 residential AOD treatment
  programs and 10 MH programs in Los Angeles County
• Staff (N 252) who have direct client contact
  were surveyed
• Clients (N 400) sampled from AOD programs were
  assessed at treatment entry, 6-month follow-up,
  and 12-month follow-up
• Focus groups (n 7) were conducted with program
  staff, clients, and community stakeholders
  

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Client Data Collection
(87.8)1
(77.5)1
Number
1An additional 18 clients (4.5) were unable to
be interviewed, refused to be interviewed, or
were deceased. There were no significant
background differences between the interviewed
and non-interviewed groups.
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Demographic Characteristics
Percent
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Background Characteristics
Percent
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Diagnosis of Mental Disorder1
1Based on DSM-IV criteria
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Alcohol/Drug Dependence1
Percent
1Lifetime based on DSM-IV criteria
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Treatment History
Percent
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Treatment Outcome at 6-month Follow-up (N 351)
No alcohol or drug use in past 30 days living
in the community (i.e., non-incarcerated, not in
residential treatment)
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Outcome Analyses

• Latent variable structural equation models
• Baseline client characteristics
• ethnicity
• MH status (SF-36, BSI)
• frequency of substance use in past 30 days
  (marijuana, heroin, cocaine/crack, alcohol)

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Outcome Analyses

• Program characteristics
• specialized dual-diagnosis groups on-site
• sum of on-site psychological services
• percent of staff who had training in COD
• Psychological service utilization
• no. of services received during follow-up period
• Time in treatment (M 93.1, SD 51.5 days)
• Outcome variables
• MH status (SF-36, BSI)
• frequency of substance use

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Follow-up
Psychological Service Utilization
Time in Drug Treatment
plt.05, plt.01, plt.001 CFI .95, RMSEA .039,
RCFI .95
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Variables Not Related to Treatment Outcome

• Client Factors
• Type of psychiatric disorder
• Legal, housing, or physical health status
• Degree of family assistance
• Quality of life, treatment history or motivation

• Treatment Factors
• Type of referral to treatment
• Self-help participation following treatment (95
  yes)
• Rapport with AOD counselor
• Satisfaction with AOD treatment

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Conclusions

• Integration of specialized services for COD in
  AOD treatment increases services utilization,
  which positively benefits client outcomes
• Staff training is critical to increasing access
  to services for COD
• African Americans had higher need for, but less
  access to, mental health services

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Policy/Practice Implications

• Continue system-wide efforts at services
  integration and staff training
• Promote innovative service collaborations
• Address health disparities in access to MH
  services

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References
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Treatment services and service delivery models
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 Grella, C.E. (2003). Contrasting the views of
substance misuse and mental health treatment
providers on treating the dually diagnosed.
Substance Use Misuse, 38(10),
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diagnosed in drug treatment Patient, treatment,
and program effects. Presentation at the annual
meeting of the American Psychological
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patients with co-occurring disorders. Poster
presented at Complexities of Co-Occurring
Conditions Conference, Washington, D.C.  Grella,
C.E., Gilmore, J. (2002). Improving service
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