Co-Occurring Disorders Expected rather than the Exception

1. Co-Occurring DisordersExpected rather than the Exception Tribal Justice & Safety – One OJP Tribal Training and Technical Assistance – Session III Shelton, WA June 5, 2007 Elizabeth I. Lopez, Ph.D. US Department of Health and Humans Services Substance Abuse and Mental Health Services Administration

2. Presentation Overview • Definition of Co-Occurring Disorders • Epidemiology of Co-Occurring Disorders • Overview of SAMHSA Co-Occurring Activities • SAMHSA Targeted Co-Occurring Programs • COSIG • COCE • National Policy Academy on Co-Occurring Disorders • Upcoming AI/AN Policy Academy • Discussion

3. Definition: Co-occurring Disorders • The term refers to co-occurring substance use (abuse or dependence) and mental disorders. • Clients said to have co-occurring disorders have one or more mental disorders as well as one or more disorders relating to the use of alcohol and/or other drugs. • A diagnosis of a co-occurring disorder (COD) occurs 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.

4. Co-Occurring Disorders Epidemiology What do we know about Co-Occurring Disorders?

5. Co-Occurring Disorders We know that co-occurring disorders are increasing becoming the expectation rather than the exception.

6. 15.2 Million 15.4 Million 4.2 Million Substance Use Disorder Only SMI Only Co-Occurring Disorders Co-Occurrence of SMI and Substance Use Disorders among Adults Aged 18 or Older: 2003 * NSDUH 2003

7. Co-Occurrence of SPD and Substance Use Disorder in the Past Year among Adults Aged 18 or Older: 2005 Up by 1 million in 2 years 14.9 Million 19.4 Million 5.2 Million Substance Use Disorder (SUD) Only Serious Psychological Distress (SPD) Only Co-Occurring SUD and SPD

8. Substance Use among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2005

9. Substance Use among Youths Aged 12 to 17, by Major Depressive Episode in the Past Year: 2005 Percent Using Substance Past Year Illicit Drug Use Past Year Marijuana Use Daily Cigarette Use in Past Month Past Month Heavy Alcohol Use Past Year Psycho-therapeutics Use

10. Co-Occurring Psychiatric Problems Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

11. Co-Occurring Disorders Expected rather than the Exception We know that individuals with a co-occurring disorder are less likely to receive treatment for BOTH disorders.

12. Past Year Treatment among Adults Aged 18 or Older with Both Serious Psychological Distress and a Substance Use Disorder: 2005 Treatment for Both Mental Health and Substance Use Problems Treatment Only for Mental Health Problems 34.3% 8.5% Substance Use Treatment Only 4.1% No Treatment 53.0% 5.2 Million Adults with Co-Occurring SPD and Substance Use Disorder Note: Due to rounding, these percentages do not add to 100 percent.

13. Age Marijuana PCP Cocaine Stimulants Tranquilizers Pain Relievers Inhalants LSD Ecstasy Heroin Sedatives Mean Age for Past Year Initiates, by Illicit Drug: 2004 NSDUH, 2004

14. Percent Using in Past Month Age in Years Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2004

15. Co-Occurring DisordersExpected rather than the Exception American Indian/Alaskan Native Communities face unique challenges with co-occurring substance abuse and psychological conditions • Historical trauma • Stigma / Discrimination • Preserving cultural healing traditions • Multiple funding streams / delivery systems for behavioral health services

16. Substance Use and AI/AN • Rates of past year use disorders were higher among American Indians and Alaska Natives than members of other racial groups for alcohol, illicit drug use, marijuana, cocaine, and hallucinogen use disorders.  • Although in the past year American Indians and Alaska Natives were less likely than persons of other racial backgrounds to have used alcohol (60.8% vs. 65.8%), they weremore likely to have an alcohol use disorder (10.7% vs. 7.6%). • For illicit drug use in the past year, American Indians and Alaska Natives were more likely than persons of other racial backgrounds both to have used an illicit drug (18.4% vs. 14.6%) and to have an illicit drug use disorder (5.0% vs. 2.9%). NSDUH 2005

17. Substance Abuse/Dependence & MDE or SPD by AI/AN and Non-AI/AN % with Co-Occurring Conditions Source: NSDUH 2004 & 2005 AI/AN=American Indian/Alaska Native; MDE=Major Depressive Episode; SPD= Serious Psychological Distress; ID= Illicit Drugs; Alc=Alcohol

18. Current Use of Illicit Drugs among Persons Aged 12 or Older, by Race: 2002 -2004 Percent Using in Past Month NSDUH 2002-2004

19. Current Use of Illicit Drugs among Youth Aged 12 to 17, by Race: 2002-2004 Percent Using in Past Month NDSUH 2002-2004

20. Current Use of Illicit Drugs among Persons Aged 26 or Older, by Race: 2002-2004 Percent Using in Past Month National Survey on Drug Use and Health 2004

21. Current Use of Alcohol among Persons Aged 12 or Older, by Race: 2002- 2004 Percent Using in Past Month National Survey on Drug Use and Health 2004

22. Heavy Use of Alcohol among Persons Aged 12 or Older, by Race: 2002-2004 Percent Using in Past Month National Survey on Drug Use and Health 2004

23. Received Substance Use Treatment in the Past Year among Persons Aged 12 or Older, by Race: 2004 Percentage

24. Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older, by Race: 2004 Percentage

25. Substance Abuse Individuals with alcohol and drug problems • Prevalence rates for current alcohol abuse and/or dependence among Northern Plains and Southwestern Vietnam veterans have been estimated to be as high as 70% compared to 11 - 32% of their white, black, and Japanese American counterparts. • The estimated rate of alcohol-related deaths for AI/AN is much higher than for the general population.

26. Mental health Exposure to trauma • The rate of violent victimization of AI/AN is more than twice the national average • Higher rate of traumatic exposure - 22% rate of PTSD for AI/AN, compared to 8% in the general U.S. population

27. Mental health Availability of Mental Health Services • Approximately 101 AI/AN mental health professionals are available per 100,000 AI/AN, compared to 173 per 100,000 for whites. • In 1996, only about 29 psychiatrists in the U.S. were of AI/AN heritage.

28. Mental health Access to Mental Health Services • The Indian Health Service (IHS) is the Federal agency responsible for providing health care to Native populations • 20% of AI/AN report access to IHS clinics, which are located mainly on reservations

29. Mental health • Medicaid is the primary insurer for 25% of AI/AN • Approximately 50% of AI/AN have employer-based insurance coverage, compared to 72% of whites • 24% of AI/AN have no health insurance, compared to 16% of the U.S. population

30. Risk and Protective Factors for Substance Use among American Indian or Alaska Native Youths • American Indian or Alaska Native youths were more likely to perceive moderate to no risk of substance use • A larger percentage of American Indian or Alaska Native youths did not perceive strong parental disapproval of youth substance use than youths in other racial/ethnic groups • American Indian or Alaska Native youths were more likely to believe that all or most of the students in their school get drunk at least once a week NSDUH 2002 - 2003

31. SAMHSA Response to addressthe Co-occurring Disorders

32. SAMHSA Co-Occurring Initiatives • Report To Congress (2002) • Federal Leadership • Cross Agency Matrix Action Plan • Co-occurring State Incentive Grants • Co-occurring Center for Excellence • Key publications: TIP 42/COD Toolkits • Co-occurring Policy Academies

33. Congress called on SAMHSA to prepare a report outlining the scope of the problem of co-occurring disorders, current treatment approaches, best practice models, and prevention efforts. This report was mandated to include: · a summary of the manner in which individuals with co-occurring disorders are receiving treatment, · a summary of practices for preventing substance abuse disorders among individuals who have a mental illness and are at risk of having or acquiring a substance abuse disorder; · a summary of evidence-based practices for treating individuals with co-occurring disorders and recommendations for implementing such practices; and · a summary of improvements necessary to ensure that individuals with co-occurring disorders receive the services they need.

34. Report to Congress on the Preventionand Treatment of Co-OccurringSubstance Abuse Disorders and Mental Disorders • Released November 2002 • Raised the awareness of Co-occurring Disorders • Included a Five-Year Blueprint for Action • SAMHSA adopted road map to address Co-occurring Disorders

36. Co-Occurring Matrix WorkgroupChair and Membership A. Kathryn Power. M.Ed. Director Center for Mental Health Service (CMHS) H. Westley Clark, M.D., J.D. M.P.H Director Center for Substance Abuse Treatment (CSAT) SAMHSA Workgroup representation: Center for Mental Health Services Office of the Administrator Center for Substance Abuse Treatment Office of Applied Studies Center for Substance Abuse Prevention Office of Communications Office of Policy, Planning & Budget

37. “No Wrong Door” Policy • Each provider should be aware that he/she has the responsibility to address the range of client needs… • wherever a client presents for care • whenever a client presents for care • properly refer clients for appropriate care as needed • follow-up on referrals to ensure clients received proper care

38. SAMHSA Co-occurring Matrix Action PlanFY 2006/2007: Purpose To expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disorders. Approximately 5.2 million individuals in the United States are estimated to be affected by co-occurring mental and substance abuse disorders. However, only a small percentage of these individuals receive treatment that addresses both disorders.

39. SAMHSA Co-Occurring Matrix Action PlanLong Term Measures • Increase the percentage of persons with co-occurring disorders who receive appropriate treatment services that address both disorders. • Increase the percentage of adolescents aged 12 – 17 who receive appropriate prevention services that address substance abuse and mental health. • Increase the percentage of persons who experience reduced impairment from their co-occurring disorders following appropriatetreatment.

40. SAMHSA Co-Occurring Matrix Action Plan:Outcome / Annual Measures • Increased percent of prevention and treatment settings that: • screen for co-occurring disorders • assess for co-occurring disorders • provide treatment to clients through collaborative, consultative and integrated models of care

41. SAMHSA Co-Occurring Matrix Action Plan: Outcome / Annual Measures • Increase the number of grantees (States, Tribes, communities, and providers) measuring and reporting on co-occurring programs, practices, and models of treatment (accountability) • Increase the number of States and Tribes with State or Tribal-Level actions plans for improving access to mainstream and specialty services for individuals with co-occurring disorders(capacity) • Increase the number of people trained to implement appropriate co-occurring prevention and integrated treatments among States, communities, providers and consumers (effectiveness)

42. SAMHSA Co-Occurring Action Plan:FY 2006-2007 Key Activities • Ensure that co-occurring disorders are a significant focus in the following major grant programs, as appropriate: Mental Health Systems Transformation SIG, Access to Recovery, and the Strategic Prevention Framework SIG • Monitor the extent to which the Co-Occurring State Incentive Grant (COSIG) addresses those populations prioritized on the SAMHSA Matrix that are appropriate and relevant to the programs within the matrix area • Create and disseminate a nationally accepted framework for developing, implementing, and sustaining co-occurring disorders prevention and treatment service systems.

43. SAMHSA Co-Occurring Matrix Action Plan:FY 2006-2007 Key Activities-continued • Increase the number of candidate programs addressing co-occurring disorders that apply for review to the National Registry of Evidence-based Programs and Practices (NREPP) addressing co-occurring disorders • Hold a policy academy for Tribal organizations, tribal communities, and tribal governments to assist in developing and sustaining service systems for the unique needs of AI/AN with and at risk for co-occurring disorders and for interested States who have not participate in a policy academy to date.

44. SAMHSA Strategic Plan for Co-Occurring Disorders

45. National Outcome Measures (NOMS)Domains • Abstinence from Drug / Alcohol Use / Reduced Morbidity • Employment / Education • Crime and Criminal Justice • Family and Living Conditions • Access / Capacity • Retention • Social Connectedness • Perception of Care • Cost Effectiveness • Use of Evidence-Based Practices

46. Co-Occurring DisordersExpected rather than the Exception Linking Co-Occurring Disorders with key SAMHSA Matrix Areas • Mental Health System Transformation • Substance Abuse Treatment Capacity • Strategic Prevention Framework

47. Treatment Implications of Comorbidity Between Alcohol and/or Drug Use Disorders and Other Psychiatric Disorders • Adolescents and adults with co-occurring disorders are not treated • Increased severity, disability and impairment in social/occupational functioning • Resistance to pharmacologic treatment • Lower probability of recovery • Increased suicidality • Increased economic burden of each comorbid condition

48. Co-Occurring Disorders Expected rather than the Exception Areas of Focus for the Treatment of COD • Innovative Models of Integrated Treatment • Sharing Lessons Learned across programs • Workforce Development • Working with Tribal, Rural Communities • Child, Adolescent, Family and Older Adults • Cultural Competency Training for Local Providers

49. Co-Occurring Disorders Expected rather than the Exception Co-Occurring Programs Co-Occurring State Incentive Grant (COSIG)

50. Co-occurring State Incentive Grants (COSIG) • Supports grantees in overcoming service delivery barriers • Supports grantees in systems change and infrastructure development • Enhancing service coordination, networks and linkages to support quality care • Improving financial incentives for integrated care • Information sharing among stakeholders • 17 grantees