An Introduction to Co-Occurring Disorders

1. An Introduction to Co-Occurring Disorders Hon. Peggy Fulton Hora Judge of the Superior Court of California (Ret.) LADCP April 12, 2012

2. “Frequent flyers” in the justice system

3. Questions 1..Have you had a professional experience where you needed information about an AOD and mental health issues? 3. What is the biggest problem you have in a court setting handling this type of person? 2.What is the percentage of persons whom you see who have co-occurring mental health and substance abuse disorders?

4. Mental Illness Defined • Mental illnesses are medical conditions that disrupt a person's • thinking, feeling, mood, • ability to relate to others • and daily functioning. • Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. NAMI

5. Addiction is a brain disease… …with biological, sociological and psychological components expressed as compulsive behavior.

6. Why is this topic important to criminal justice? Approximately 5-7% of the U.S. population has a serious mental illness But 14.5 % of men and 31% of women in custody have a SMI 33% of drug court participants have a co-occurring disorder “Task Force for Criminal Justice Collaboration on Mental Health Issues,” AOC CA 2010

7. DSM 301.7 Antisocial Personality Disorder Pervasive pattern of disregard for and violation of the rights of others Begins in childhood or early adolescence and continues into adulthood Deceit and manipulation are central features Impulsivity and disregard of consequences 3% males, 1% females general population 20-25% for SA tx; 30% criminal offenders

8. Psychopathy Mental disorder marked by affective, interpersonal, and behavioral abnormalities A demonstrated incapacity for empathy and guilt, impulsivity, egocentricity, and chronic violations of social, moral, and legal norms 3.5% in SA Tx 8% in criminal justice system

9. Largest mental hospital in the U.S.? Los Angeles County Jail with 3,000 MI inmates every day Earley, Pete, Crazy: A Father's Search Through America's Mental Health Madness (Putnam, 2006)

10. Recidivism rates higher Recidivism rates for probationers with mental illness are nearly double (54% vs. 30%) Those with MI are more likely to have their probation revoked than those without Parolees have higher violation rates Lorena L. Dauphonot, “The efficacy of community correctional supervision for offenders with severe mental illness 57 (9-B) Dissertation Abstracts International: Section B: The Sciences and Engineering 5912 (March 1997)

11. Crime rates Persons with mental conditions report being under the influence at the time of the offense in greater numbers than those who do not have such conditions

12. Louisiana Numbers 183,000 adults live with SMI and about 49,000 children live with serious mental health conditions In 2008, approximately 9,100 adults with mental illnesses were incarcerated in prisons in Louisiana Public mental health system provides services to only 17 percent of adults who live with serious mental illnesses in the state NAMI State Advocacy 2010

13. Grading the State • Health Promotion and Measurement: D • Financing & Core Treatment/Recovery Services: D • Consumer & Family Empowerment: D • Community Integration and Social Inclusion: D “D” “D” “D” “Grading the States 2009,” NAMI

14. Who do we see in court? People with significant multiple drug problems People with psychiatric disorders that can benefit from medication, including psychotic disorders People whose accommodation and general life functioning is brittle High risk, high need on Risk/Need Assessment instruments

15. Lethality According to U.S. Justice Department statistics, 15.8 percent of the defendants in cases of children killed by a parent had a history of untreated mental illness. People with SMI commit 5,000 suicides and 5% of all homicides in the U.S.

16. Shortage of hospital beds for MI For every 20 public psychiatric beds in the US in 1955, there is only one today “Untreated persons with severe mental illness have become major problems in homeless shelters, jails, public parks, public libraries and emergency rooms.” “TAC Study Reveals Severe Shortage of Psychiatric Beds,” Catalyst, Treatment Advocacy Center (Summer 08)

17. If punishment won’t work, …then what’s a judge to do? ASSIGNMENT: Write down alternatives to “punishment” for people with co-occurring disorders

18. Incarceration When you use jail as a sanction, what happens?

19. Issues Sanctions, Incentives and Treatment Responses Incarceration Victim input Mental Health Court/docket Courtroom Control Others?

20. What is a co-occurring disorder? More than one diagnosable illness in the same individual Types of co-occurring: medical, psychiatric, developmental, etc.

21. What is a co-occurring substance abuse and mental health disorder? Substance use, abuse, addiction Plus one (or more) diagnosable mental health disorders, e.g., Bi-Polar Schizophrenia Depression PTSD

22. “Co-occurring mental health disorders should be the expectation, not the exception.” Dr. Ken Mincoff

23. Prevalence of Co-Occurring Epstein, Joan, et al., “ Serious Mental Illness and Its Co-Occurrence with Substance Use Disorders,” 2002. Office of Applied Sciences, SAMHSA

24. Prevalence of Co-occurringDisorders 4.2 million adults (18+ y.o.) have a serious mental illness (SMI) and a substance use disorder Illicit drug use is more than twice as high among persons with a SMI than without (27% to 12.5%) 2003 NSDUH data

25. 4 million people with co-occurring More than half (52%) receive neither MH or SA Tx Of those receiving tx, 34% receive only MH 2% for SA tx 12% received tx for both “4 Million Have Co-Occurring Serious Mental Illness, Substance Abuse,” SAMHSA News (Sept./Oct. 2004)

26. Co-Occurring Disorders by Severity Mental Illness High Severity Low Severity Substance Abuse High Severity

27. Co-occurring disorders are expensive In central TX in the last 6 years just 9 residents accounted for 2,678 visits. One treated in Er > 100 times Most have hx of substance abuse and mental illness Cost = $2.7 million “What an Outrage,” AARP Bulletin (June 2009)

28. Mental Health + Substance Use Each can effect the onset of the other E.g., patients with psychotic disorders who smoked marijuana at an early age developed symptoms almost three years sooner than those who did not Matthew Large, et al., “Cannabis Use and Earlier Onset of Psychosis A Systematic Meta-analysis” , Arch Gen Psychiatry.Published online (February 7, 2011) Its severity E.g., marijuana may contribute to the severity of schizophrenia’s symptoms (Smesny, et al, ”Cannabinoids influence lipid-arachidonic acid pathways in schizophrenia,” Neuropsychopharmacology32:2067-2073, 2007) “Cannabis Could Increase Risks Of Psychotic Illness By 40 Percent,” Cardiff University (2007, August 1). Each can mask the other

29. Which comes first? • Recent study showed alcohol abuse may lead to an increased risk of depression, not the opposite • May be genetic link • Fergusson et al., “Tests of Causal Links Between Alcohol Abuse or Dependence and Major Depression,” Archives of General Psychiatry 66 (3) (2009)

30. Treat Both Disorders “Ample evidence in the literature supports the notion that inadequately treated psychiatric symptoms interfere with addiction treatment.”

31. Co-Occurring Disorder Center

32. Mentally ill offenders’ re-entry Major program components that improve chance of MI offenders reentering society: Coordinated pre-release planning up to 3 months prior to release Intensive post-release case management Theurer, Gregory and David Lovell 47(4) Journal of Offender Rehabilitation (2008) 385-406

33. Re-entry, cont. Residential support services Community supervision Co-occurring tx delivered by mental health staff with SA training

34. Some Strategies to Consider Use jail sparingly so medication regimes are not compromised Look for creative alternative to incarceration like ordering the defendant to set up chairs for peer support group Link volunteer work with something defendant likes to do (work outdoors, work with animals, etc.)

35. Strategies, cont. Make sure defendant receives integrated substance abuse and mental health treatment Monitor cases closely – community corrections or the court for high risk/high need offenders

36. To reduce recidivism Ask, “Are they managing their illness”? Going to tx and support groups Taking meds Accepting their illness Find an “honest broker” to services. Reporting deviations from the tx plan Providing gender and culturally competent tx Using evidence-based practices Dave Kelly, Deputy District Attorney, Brooklyn Mental Health Court

37. WOMEN

38. Mental health issues • Co-morbidity complicates and exacerbates the problems • Almost 12% of mothers in the U.S. has serious mental illness; 3.2% had SMI + SA • Up to 95% of parents in tx programs have co-occurring disorders

39. Post Traumatic Stress Disorder • 30-57% women in treatment meet criteria for PTSD • 45-85% of battered women meet criteria • Co-morbidity for PTSD and substance use disorders is 2-3xs higher for females

40. Trauma-informed Care “Understanding women in court,” SAMHSA, Center on Women, Violence and Trauma (2006) Community corrections, prosecution, defense and the court must become “trauma-informed” Substance abuse and other mental health issues are closely associated with trauma SA/MH drives the justice system—both criminal and child abuse and neglect cases

41. Women with Co-Occurring Primary Drugs of Choice OAS, 2002

42. Cocaine / Alcohol Abusers with Comorbid Psychiatric Disorder MEN Anxiety 48% Depression 36% Bipolar 6% Panic disorder 10% Social phobia 14% PTSD 24% WOMEN 70% 40% 4% 18% 10% 46%

43. Men vs. Women in Custody • Women inmates have >symptomology • diagnosed with mental health problems 3xs rate of men Symptoms Diagnosed

44. Women with Co-Occurring More Likely Than Men to be: Poor Uneducated Poor job skills Receive public assistance Report more relatives with AOD problems Care for more dependents Depressed, anxious, have eating disorders and lower self-esteem “Women with Co-Occurring Mental Illness and Substance Abuse,” AIA Center (May 2005)

45. Jennifer • Repeated phone calls to ex • AOD issues? • MH issues? • How do you get the information you need?

46. CHILDREN and adolescents

47. Teens with co-occurring disorders

48. Addressing Teens’ Issues Consider arrest histories of adolescent and young adult clients Coordinate services between MH, juvenile and criminal justice Provide those at high risk with best services targeted at reducing antisocial behavior Provide for continuity of services during ages 16-25 Davis, Maryann, PhD, et al., “Adolescent Mental Health Gender Differences in Arrest Onset & Risk,’ Center for Mental Health Services Research, U Mass Med. School Issue Brief 5:1 (Jan. 2008)

49. 25 years to grow a mature one • 18-25 “apprentice adults” • Exposure to traumatic stress can affect developmental processes • Increases risk of SA, criminal activity, homelessness and revictimization

50. Early onset of use • Every year before 21 increases likelihood of problem drinking by 12% • Early drinkers need more alcohol to get high