What are Behavioral Health Disorders?

1. What are Behavioral Health Disorders? • When we use the term, we are referring to: • Mental disorders (or mental illnesses) + substance use disorders = behavioral health disorders • However, the term “behavioral health” is not universally agreed upon in the field • Historical context • Differences between mental health and substance use treatment communities/systems Council of State Governments Justice Center

2. What are Mental Disorders? • A syndrome characterized by clinically significant disturbances in a person’s thinking, emotional state, and/or behavior that disrupt his/her ability to work or carry out other daily activities, and engage in satisfying personal relationships • The diagnosis of a mental disorder should have clinical utility: it should help determine prognosis, plan treatment, and potentialoutcomes. • Individuals whose symptoms do not meet full criteria for a disorder may still need treatment or care. Council of State Governments Justice Center

3. The Key Dimensions of Mental Disorders • Anxiety • Feelings of fear or dread, rapid heart rate, shortness of breath, lightheadedness • Disturbances in perception and thinking • Hallucinations, delusions • Disturbances of cognition • Difficulty organizing, processing, and recalling information • Disturbances of mood • Emotional highs or lows as prominent feature Council of State Governments Justice Center

4. When Do Symptoms Cross a Threshold to Become a Disorder? • Mental illness and mental health exists on a continuum that is based on the: • Nature and severity of symptoms • Duration of symptoms • Extent to which symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Council of State Governments Justice Center

5. How Are Disorders Determined and Described? Council of State Governments Justice Center

6. How Are Mental Disorders Diagnosed? • The Diagnostic and Statistical Manual Fifth Edition (DSM-5) of the American Psychiatric Association provides a common language and typology for mental disorders in both children and adults. • APA published first classification of mental disorders in 1844 as forerunner of DSM • Four iterations post WW II with DSM-IV-TR published in 2000 • The DSM-5 was released by the American Psychiatric Association in May 2013 • DSM 5 builds on its predecessors Council of State Governments Justice Center

7. What Are Substance Use Disorders? Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. National Institute on Drug Abuse: Drug Facts- Treatment Approaches for Drug Addiction: http://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction • The annual total estimated societal cost of substance abuse in the United States is $510.8 billion Source: Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014 Executive Summary and Introduction. HHS Publication No. (SMA) 11-4629 Summary. Rockville, MD: Substance Abuse and Mental Health Services Administration,2011. Council of State Governments Justice Center

8. Not all Mental Illnesses are Alike: Mental Illness in the General Population Council of State Governments Justice Center

9. In a Given Year… • 22% of the United States adult population will be diagnosed with a behavioral disorder Council of State Governments Justice Center

10. What Are Co-Occurring Disorders? • The term refers to co-occurring substance use (abuse or dependence) and mental health disorders. • Clients said to have co-occurring disorders when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder. COCE, 2007 Council of State Governments Justice Center

11. MAJOR MENTAL ILLNESS A biological illness. Hereditary (in part). Chronicity Incurability Leads to lack of control of behavior and emotions Affects the whole family Symptoms can be controlled with proper treatment Progression of the disease without treatment Disease of denial Facing the disease can to lead to depression and despair.  Disease is often seen as a “moral issue,” due to personal weakness rather than biological causes Feelings of guilt and failure Feelings of shame and stigma Physical, mental, and spiritual disease ALCOHOLISM/ADDICTION A biological illness. Hereditary (in part). Chronicity Incurability Leads to lack of control of behavior and emotions Affects the whole family Symptoms can be controlled with proper treatment Progression of the disease without treatment Disease of denial Facing the disease can to lead to depression and despair.  Disease is often seen as a “moral issue,” due to personal weakness rather than biological causes Feelings of guilt and failure Feelings of shame and stigma Physical, mental, and spiritual disease PARALLELS: MENTAL ILLNESSES AND ADDICTIONS(Minkoff, 1996) Council of State Governments Justice Center

12. What is the Relationship between Mental Illnesses and Substance Use Disorders? • Acute and chronic substance use can produce psychiatric symptoms • Substance withdrawal can cause psychiatric symptoms • Substance use can mask psychiatric symptoms • Psychiatric disorders can mimic symptoms associated with substance use • Acute and chronic substance use can exacerbate psychiatric disorders • Acute and chronic psychiatric disorders can exacerbate the recovery process from addictive disorders Council of State Governments Justice Center

13. Consequences of Co-occurring Disorders • Increased vulnerability to relapse and rehospitalization • More psychotic symptoms • Inability to manage finances • Housing instability and homelessness • Noncompliance with medications and treatment • Increased vulnerability to HIV infection and hepatitis • Increased contact with the criminal justice system Council of State Governments Justice Center

14. Substance Abuse & Addiction in Criminal Justice Percent of Population 8 % Source: Compton et al., Am J Psychiatry, 2010. CSG Justice Center

15. SMI and Co-Occurring Substance Use Disorders (CODs) Prevalence of SMI and CODs in Jail Populations General Population Jail Population 28% 83% 17% Serious Mental Illness Serious Mental Illness COD No Serious Mental Illness No Serious Mental Illness No COD Sources: Kessler RC, Chiu WT, Demler O, Walters EE. “Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication” (NCS-R). Archives of General Psychiatry, 2005 Jun; 62 (6): 617-27; Henry Steadman, Fred C. Osher, Pamela C. Robbins, Brian Case, and Steven Samuels, “Prevalence of Serious Mental Illness Among Jail Inmates,” Psychiatric Services, 60 (2009): 761-65; Abram, K. M., Teplin, L. A. (1991). “Co-occurring disorders among mentally ill jail detainees,” American Psychologist, 46 (10), 1036–1045. Council of State Governments Justice Center

16. What Are Co-Occurring Disorders? (contd.) • Among the jail population: 83% 28% 17% Co-Occurring Substance Use Disorder Serious Mental Illness No Co-Occurring Substance Use Disorder No Serious Mental Illness Council of State Governments Justice Center

17. The Problem: Overrepresentation of Persons with Behavioral Disorders. Why? • Arrested at disproportionately higher rates • Co-occurrence of substance use disorders • Homelessness • Stay longer in jail and prison • Limited access to health care • Low utilization of EBPs • High recidivism rates • More criminogenic risk factors Council of State Governments Justice Center

18. What Accounts for the Problem?High Recidivism Rates on Reentry • Screened 2,934 probationers for mental illness: • 13% identified as mentally ill • Followed for average of two years No more likely to be arrested … … but 1.38 times more likely to be revoked Source: Vidal, Manchak, et al. (2009); see also: EnoLouden & Skeem (2009); Porporino & Motiuk (1995) Council of State Governments Justice Center

19. What Accounts for the Problem? Those with Mental Illnesses Have More “Central 8” Dynamic Risk Factors ** ….and these predict recidivism more strongly than mental illness Source: Skeem, Nicholson, & Kregg (2008) Council of State Governments Justice Center 19

20. The Behavioral Health – Criminal Justice Problem in Summary • We arrest them more often . . . • We stress them while they’re incarcerated . . . • We keep them incarcerated longer . . . • They don’t get access to adequate mental health care . . . • They are more likely to “fail” community supervision. Council of State Governments Justice Center