ONE SKY CENTER: Best Practice Behavioral Health Approaches for American Indians and Alaska Natives

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ONE SKY CENTERBest Practice Behavioral Health
Approaches for American Indians and Alaska Natives

• Elizabeth Hawkins, PhD, MPH
• Dale Walker, MD, Patricia Silk Walker, PhD,
  Douglas Bigelow, PhD, Laura Loudon, MS
• Warrior Spirit Conference, Albuquerque, April
  22-23, 2004

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Overview

• Introduction to One Sky Center
• Overview of comorbidity issues
• AI/AN comorbidity
• Comorbidity best practices
• Barriers to integrated treatment
• Solutions

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• INTRODUCTION TO ONE SKY CENTER

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One Sky Center

• Funded by SAMHSA (CSAT CSAP)
• Envisioned as an innovative NRC dedicated to
  identification and fostering of effective and
  culturally appropriate substance abuse prevention
  and treatment. -Charles Currie, SAMHSA, July
  2003

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OSC Goals

• Promote and nurture effective and culturally
  appropriate prevention and treatment
• Identify and disseminate evidence-based
  prevention and treatment practices
• Provide training and technical assistance
• Help to expand capacity and improve quality in
  behavioral health care services

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OSC Partners
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Alaska Native Tribal Health Consortium

• ANTHC is a non-profit health organization owned
  and operated by Alaska Native tribal governments
  and their regional health corporations.
• Provides comprehensive services statewide to
  Alaska Natives.
• Offers
• Medical Center specialty services
• Health and sanitation facility development
• Training for Alaska Native health professionals
• Health system statewide network support
• Community and environmental health services
• http//www.anthc.org

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Jack Brown Youth Treatment Center

• Operated by the Cherokee Nation Health Service
  and located in Tahlequah, OK
• Catchment area is primarily Kansas, Oklahoma, and
  Texas
• Number of tribes served 1997-2003 71
• CARF accredited, 20-bed co-educational facility
  for youth 13-18 years of age
• Usual length of stay is between 30 to 120 days
• Dual Diagnosis approach that targets physical,
  mental, emotional, and spiritual growth
• Special emphasis on art therapy as a means of
  health promotion

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National Indian Youth Leadership Project

• A non-profit organization located in Gallup, NM
  (founder is McClellan Hall)
• Youth development programs include
• Service learning
• Experiential learning
• Traditional, culturally-derived rites of passage
• Academic enrichment
• Ongoing projects include
• Project Venture
• Walking in Beauty
• Web of Life
• 21st Century Learning Center
• Turtle Island Project
• Sacred Mountain Learning Center
• http//www.niylp.org

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United Indian Involvement

• A non-profit organization that provides services
  to the Los Angeles American Indian community.
• The Los Angeles American Indian Health Project
• Robert Sundance Family Wellness Center
• Robert Sundance Workforce Development Program
• Ah-No-Ven (Healing) Home Youth Regional
  Treatment Center
• American Indian Clubhouse
• Seven Generations Child and Family Counseling
  Center
• Native Pathways to Healing
• Circles of Care Program
• http//www.laindianhealth.com

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White Bison Inc.

• An American Indian non-profit organization based
  in Colorado Springs (founder is Don Coyhis)
• Offers sobriety, recovery, addictions prevention,
  and wellness/wellbriety learning resources
• White Bisons mission is to assist in bringing
  100 Native American communities into healing by
  2010
• The principle underlying White Bison is living in
  harmony with natural law
• Ceremonies are used to help individuals and
  communities get back into harmony
• http//www.whitebison.org

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Sample of OSC Current Projects

• SAMHSA portfolio project
• Best practices consensus panel
• Needs assessment of IHS Youth Regional Treatment
  Centers
• Alaska Behavioral Health Aide program
• CAPT and ATTC needs assessment
• Recruitment and training of AI/AN professionals
• Technical assistance
• Development and dissemination of prevention and
  treatment resources

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• OVERVIEW OF COMORBIDITY ISSUES

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Comorbidity Defined

• Individuals who have at least one mental
  disorder as well as an alcohol or drug use
  disorder. While these disorders may interact
  differently in any one person.at least one
  disorder of each type can be diagnosed
  independently of the other.
• - Report to Congress of the Prevention and
  Treatment of Co-Occurring Substance Abuser
  Disorders and Mental Disorders, SAMHSA, 2002

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Lifetime History
Mental Disorder 22.5 Comorbidity 29 3.1
1.5 1.7 1.1
Alcohol Disorder 13.5 Comorbidity 45
Drug Disorder 6.1 Comorbidity 72
Regier, 1990
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Prevalence and Pattern of COD

• 7-10 million Americans are affected each year
• Antisocial personality disorder, bipolar
  disorder, and schizophrenia are most likely to
  coexist with a substance use disorder
• Individuals with COD have a high prevalence of
  trauma histories and related symptoms
• Individuals with COD are more likely to have
  cardiovascular disease, cirrhosis, or cancer than
  someone without such a diagnosis

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Prevalence and Pattern in Youth

• Among adolescents entering substance abuse
  treatment, 62 of males and 83 of females had at
  least one emotional/behavioral disorder
• Almost 90 of those with a lifetime co-occurring
  disorder had at least one mental health disorder
  prior to the onset of a substance abuse disorder
• Mental disorder likely to occur in early
  adolescence, followed by the substance abuse
  disorder 5-10 years later

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Multiple Diagnoses Increase

• Treatment seeking
• Use of services
• Likelihood of no services
• Treatment costs
• Poor outcome
• Suicide risk

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Affective Disorders and SUD

• 56 of people with Bipolar Disorder have a
  substance use disorder
• 32 of people with other affective disorders have
  a substance use disorder
• 20 of youth with depression have history of
  substance abuse
• 15 75 of patients in substance abuse treatment
  have affective disorder
• Use of TCAs and SSRIs show hope for treating
  affective disorder and reducing alcohol and drug
  intake

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Schizophrenia and SUD

• 47 have substance use disorders
• Alcohol use may decrease negative symptoms
  (depression, apathy, anhedonia, passivity and
  withdrawal)
• May also decrease positive symptoms of
  hallucinations and paranoia
• Schizophrenics often use and abuse stimulants
• Drug-induced psychosis marked by prominent
  hallucinations or delusions

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Anxiety Disorders and SUD

• 27 have a substance use disorder
• Anxiety disorders may be treated with TCAs, SSRIs
  and Benzodiazepines (with caution)
• Generalized anxiety disorder Buspirone shown to
  treat anxiety and reduce alcohol consumption
• Social anxiety is a big risk factor for alcohol
  and drug use
• With PTSD, people will often use drugs or alcohol
  to sleep and stop recurrent nightmares, or to
  reduce anxiety

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Disruptive Disorders and SUD

• 23 of people with ADHD have a substance use
  disorder
• Combination of ADHD and CD place a child at
  greater risk of substance abuse than either one
  alone
• The greater the number of CD symptoms, the more
  severe the substance abuse is likely to be
• When CD precedes substance abuse, youth are at
  highest risk for ongoing delinquency and drug use
  in adulthood
• Stimulants are a primary treatment choice but
  risk of abuse is high

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Rates of Treatment by Type and Severity Level of
the Disorder
 
 
 
 
 
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• COMORBIDITY AMONG AMERICAN INDIANS AND ALASKA
  NATIVES

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American Indians

• Have same disorders as general population
• Greater prevalence
• Greater severity
• Much less access to treatment
• Cultural relevance more challenging
• Social context disintegrated

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Mental Health Culture, Race and Ethnicity

• American Indians
• Less likely to receive needed mental health
  services
• Often receive a poorer quality of mental health
  care
• Are underrepresented in mental health research
• Have more homelessness and incarceration
• Have more trauma exposure, suicide, homicide

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Trends among AI/AN Youth

• Lifetime substance use rates are similar to
  non-Indian teens, but AI/AN youth are more likely
  to
• Use tobacco, inhalants, alcohol, and marijuana
  daily
• Consume alcohol in a binge-drinking style
• Engage in high risk behaviors and experience
  harmful consequences
• AI/AN youth tend to initiate substance use at a
  younger age
• Higher rates of polysubstance use
• Substance use often does not follow the Gateway
  model
• Highest rates of emotional/behavioral problems
  and suicide

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Alcohol and Other Drug Use

• May cause or mimic psychiatric symptoms
• May initiate or exacerbate a psychiatric disorder
• Can mask psychiatric symptoms
• May last for days to weeks
• Drug-induced psychiatric symptoms may clear
  spontaneously

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Inpatient Psychiatric Care/100,000
Total Male Female National 44 56
32 AI/AN 99 78 21 Asian 23 13
10 Black 171 123 48 Hispanic 63 46
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SAMHSA, 2000
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Native American Admissions, 1999

• Total Male Female
• Admissions (Thousands) 43.2 28.2 15.0
• Primary Substance (percent)
• Alcohol 62.2 65.7 55.6
• Marijuana 12.4 13.0 11.4
• Opiates 9.0 8.0 10.8
• Cocaine 6.4 5.0 8.9
• Stimulants 5.4 4.0 8.2
• Other 4.7 4.5 5.0
• Total 100.0 100.0 100.0

Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Past Year Illicit Drug Use
Total Female Male Total
11.9 9.8 14.1 Native American 19.8 23.3 15.6 N
on-Hispanic White 11.8 9.9 13.9 Non-Hispanic
Black 13.1 10.2 16.6 Hispanic Central
American 5.7 4.2 7.7 Hispanic Cuban
8.2 5.5 11.4 Hispanic Mexican 12.7
9.2 15.8
Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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Prevalence of Alcohol Dependence
Total Female Male Total 3.5 2.1
4.9 Native American 5.6 6.8 4.3 Non-Hispanic
White 3.4 2.2 4.8 Non-Hispanic
Black 3.4 2.0 5.2 Hispanic Central
American 2.8 0.8 5.4 Hispanic
Cuban 0.9 0.5 1.3 Hispanic Mexican 5.6 2.6 8
.4
Source 1999 SAMHSA Treatment Episode Data Set
(TEDS).
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• COMORBIDITY BEST PRACTICES

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Best Practices

• Examples and cases that illustrate the use of
  community knowledge and science in developing
  cost effective and sustainable survival
  strategies to overcome a chronic illness.
• - WHO

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Service Planning Guidelines

• Dual diagnosis is an expectation, not an
  exception.

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Service Planning Guidelines

• Dual diagnosis is an expectation, not an
  exception.
• People with COD can be organized into 4 subgroups
  for service planning purposes.

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Co-occurring Disorders by Severity
High Severity
III Less severe mental disorder/ more severe
substance abuse disorder
IV More severe mental disorder/ more severe
substance abuse disorder
Alcohol and other drug abuse
I Less severe mental disorder/ less severe
substance abuse disorder
II More severe mental disorder/ less severe
substance abuse disorder
High Severity
Low Severity
Mental Illness
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Service Planning Guidelines

• Dual diagnosis is an expectation, not an
  exception.
• People with COD can be organized into 4 subgroups
  for service planning purposes.
• Treatment success involves formation of
  empathetic, hopeful, integrated treatment
  relationships.

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Service Planning Guidelines

• Dual diagnosis is an expectation, not an
  exception.
• People with COD can be organized into 4 subgroups
  for service planning purposes.
• Treatment success involves formation of
  empathetic, hopeful, integrated treatment
  relationships.
• Treatment success is enhanced by providing
  interventions for both disorders continuously
  across multiple treatment episodes.

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Unified Services Plan

• Case management should address
• Mental health
• Education/vocation
• Leisure/social
• Parenting/family
• Housing
• Financial
• Daily living skills
• Physical health

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Service Planning Guidelines

• Dual diagnosis is an expectation, not an
  exception.
• People with COD can be organized into 4 subgroups
  for service planning purposes.
• Treatment success involves formation of
  empathetic, hopeful, integrated treatment
  relationships.
• Treatment success is enhanced by providing
  interventions for both disorders continuously
  across multiple treatment episodes.
• Integrated dual diagnosis-specific interventions
  are recommended.

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Service Planning Guidelines

• Interventions need to be matched to diagnosis,
  phase of recovery, stage of treatment, and stage
  of change.

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Stages of Change

precontemplation
relapse
contemplation
maintenance
preparation
action
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Service Planning Guidelines

• Interventions need to be matched to diagnosis,
  phase of recovery, stage of treatment, and stage
  of change.
• Interventions need to be matched according to
  level of care and/or service intensity
  requirements, utilizing well-established level of
  care assessment methodologies.

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Service Coordination by Severity
High Severity
III Locus of care substance abuse system
IV Locus of care state hospitals, jails,
prisons, emergency rooms, etc.
I Locus of care primary health care settings
II Locus of care mental health system
Alcohol and other drug abuse
High Severity
Low Severity
Mental Illness
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Service Planning Guidelines

• Interventions need to be matched to diagnosis,
  phase of recovery, stage of treatment, and stage
  of change.
• Interventions need to be matched according to
  level of care and/or service intensity
  requirements, utilizing well-established level of
  care assessment methodologies.
• There is no single correct dual diagnosis
  intervention or program. Intervention must be
  individualized.

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Service Planning Guidelines

• Interventions need to be matched to diagnosis,
  phase of recovery, stage of treatment, and stage
  of change.
• Interventions need to be matched according to
  level of care and/or service intensity
  requirements, utilizing well-established level of
  care assessment methodologies.
• There is no single correct dual diagnosis
  intervention or program. Intervention must be
  individualized.
• Outcomes of treatment interventions are similarly
  individualized.

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Treatment Models

• Sequential treatment First one provider, then
  the other
• Parallel treatment Two separate providers at
  the same time
• Integrated treatment Both services provided by
  same clinician or group of clinicians

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Integrated Treatment

• Any mechanism by which treatment interventions
  for co-occurring disorders are combined within
  the context of a primary treatment relationship
  or service setting.
• -CSAT

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Effective Interventions for Adults

• Cognitive/Behavioral Approaches
• Motivational Interventions
• Psychopharmacological Interventions
• Modified Therapeutic Communities
• Assertive Community Treatment
• Vocational Services
• Dual Recovery/Self-Help Programs
• Consumer Involvement
• Therapeutic Relationships

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Effective Interventions for Youth

• Family Therapy
• Multisystemic Therapy
• Case Management
• Therapeutic Communities
• Circles of Care

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NIDA Recommended Approaches

• Contingency Management
• Relapse Prevention Therapy
• Community Reinforcement Approach
• Motivational Enhancement Therapy

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• BARRIERS TO INTEGRATED TREATMENT

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Disconnect Between Systems

• Professionals are undertrained in one of two
  domains
• Patients are underdiagnosed
• Patients are undertreated
• Neither integrates well with medical and social
  service

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Difficulties of Integrated Approach

• Separate funding streams and coverage gaps
• Agency turf issues
• Different treatment philosophies
• Different training philosophies
• Lack of resources
• Poor cross training
• Consumer and family barriers

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Agencies Involved in Health Services

• Indian Health Services
• Bureau of Indian Affairs
• Tribal health programs
• Urban Indian health programs
• County and state agencies

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Reasons for lack of partnership

• Stigma
• Limited access
• No critical mass
• Time
• Cost
• Competing priorities
• Disparate agenda
• History of unsuccessful collaboration

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• SOLUTIONS

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Identify Best Practices
Best Practice
Mainstream Practice
Clinical/services Research
Traditional Healing
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World Conference on Science

• Recommended that scientific and indigenous
  knowledge be integrated in interdisciplinary
  projects dealing with culture, environment and
  chronic illness.
• - 1999

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Partnered Collaboration

Community-Based Organizations
Grassroots Groups
Research-Education-Treatment
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What makes a partnership work?

• Trust do away with stereotypes
• Real participation at all levels
• Build in incentives for all stakeholders
• Education and training of all stakeholders
• Dissemination of knowledge
• Enhanced communication
• Social to scientific interaction

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Circle of Care
Traditional Healers
Child Adolescent Programs
Primary Care
AD Programs
Best Practices
Boarding Schools
Prevention Programs
Colleges Universities
Emergency Rooms
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(No Transcript)
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Resources

• National Clearinghouse of Alcohol and Drug
  Information (NCADI)
• http//www.health.org
• National Institute of Alcohol Abuse and
  Alcoholism (NIAAA)
• http//www.niaaa.nih.gov
• National Institute of Drug Abuse (NIDA)
• http//www.nida.nih.gov
• National Institute of Mental Health (NIMH)
• http//www.nimh.nih.gov
• Treatment Improvement Protocol (TIP) Series
• [phone]
• Monitoring the Future Study
• http//www.monitoringthefuture.org

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• For more information, contact
• Elizabeth Hawkins, PhD, MPH
• One Sky National Resource Center
• 503-494-3703
• hawkinse_at_ohsu.edu
• Visit us online at www.oneskycenter.org