Transcript What a Difference 5 Minutes can Make in the Lives of

What a Difference 5 Minutes
can make in the Lives of
Children and Adults:
Screening for the Co-Occurring
Disorders of Mental Health and
Substance Abuse
The 2007 Zarrow
Mental Health Symposium
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Presenters
Mary E. Dillon, MSW, Ed.D
OU OK-COSIG Associate Evaluator, Tulsa.
Andrew L. Cherry, DSW, ACSW
Oklahoma Endowed Professor of Mental Health
University of Oklahoma, School of Social Work, Tulsa.
OU OK-COSIG Project Evaluator
L. D. Barney, ICAADC, MSW Student,
University of Oklahoma, Norman Campus.
OK-COSIG Program Specialist, ODMHSAS, OKC
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Failing People with a
Co-occurring Disorder
► The
evidence from the field is that people with the cooccurring disorders of Mental Health, Trauma related
Mental Health Issues and Substance Abuse are NOT
benefiting from traditional mental health and substance
abuse treatment.
► The evidence that current options are ineffective comes
in the form of multiple treatment failures, years of lost
productivity, and higher levels of involvement in the
justice system.
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Rate of Incidence: Adults
► The
need for better treatment options for people
with a co-occurring disorder received critical
support when the 2002 National Survey on Drug
Use and Health in the United States reported that
over 22% of adults with a serious mental illness
and those who abuse alcohol or other drugs have
a co-occurring problem of mental health and
substance abuse.
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Rate of Incidence: Children
► A substantial
number of children and adolescents
also experience substance abuse disorders,
mental disorders, or co-occurring disorders. A
study of mental health service use among youth
reveals that nearly 43% of youth who receive
mental health services in the United States have
been diagnosed with a co-occurring disorder
(CMHS, 2001).
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Understanding Co-Occurring
Disorders
► The
time between the onset of a mental disorder
and a subsequent substance abuse disorder
represents an important “window of
opportunity” in which a co-occurring disorder
may be prevented (Ziedonis, 1995). It suggests
not only the value of early diagnosis and
treatment of mental disorders in youth, but also
the critical role for alcohol and drug testing as an
important tool for prevention, early identification
and intervention.
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The Window of Opportunity
► More
than 40% of youth, ages 11 to 17, who had
either a substance use diagnosis or moderate to
severe functional impairment as a result of
substance use, reported problems that included
involvement with the police, missing school or
work, changing friends to those who drink or use
drugs, getting into arguments with family and
friends, and getting in trouble in school
(Manteuffel et al., 2002).
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Missing the Window
► When
an adolescent is “acting out”, most parents
hope that it is a drug related behavior, rather than
a mental health disorder. However, we as
clinicians need to screen the adolescent for a cooccurring disorder, and if indicated, help parents
explore both issues. If we don’t we are missing a
“window of opportunity” and it may be another
8 to 10 years before the adolescent is diagnosed
with a co-occurring disorder.
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Missing the Window
► When
an adolescent is “acting out”, most parents
hope that it is a drug related behavior, rather than
a mental health disorder. However, we as
clinicians need to screen the adolescent for a cooccurring disorder, and if indicated, help parents
explore both issues. If we don’t we are missing a
“window of opportunity” and it may be another
8 to 10 years before the adolescent is diagnosed
with a co-occurring disorder.
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Barriers to Treatment
► Children
and adolescents with co-occurring
substance abuse disorders and mental disorders,
and their families face special challenges to
treatment. In part, the challenges arise because
more knowledge is needed about the prevalence
(rates) of co-occurring substance abuse disorders
and mental disorders among children and
adolescents. We also need developmentally
appropriate assessment standards to help in the
screening and diagnostic process.
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Effective Interventions
► While
children and adolescents with cooccurring substance abuse and mental health
disorders are not simply “small adults”, some of
the treatment issues are similar. As with adults,
co-occurring disorders in children and
adolescents vary in level of severity; as with
adults, assessment is an ongoing process. Youth
should be able to move back and forth across the
level of care continuum based on their progress
and changes in environment.
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A Major Barrier
► One
of the major barriers to identifying people
with a co-existing disorder has been the cost
involved in assessment.
► This process has typically required two
assessments. One assessment focused on mental
health disorders.
► The second focused on substance abuse
disorders.
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Eliminating Some of the Burden
► To
eliminate part of this burden, a rapid-response
screen was developed. The AC-OK Screen for
Co-Occurring Disorders (Mental Health, Trauma
Related Mental Health Issues & Substance
Abuse) is intended to help determine if the
person requesting help needs to be clinically
assessed for a co-existing mental health and
substance abuse problem.
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The Reliability and Validity
of the AC-OK Screen
for Co-Occurring Disorders
(Mental Health, Trauma Related
Mental Health Issues &
Substance Abuse)
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AC-OK Screen for
Co-Occurring Disorders
► The
findings that support the reliability and
validity of this screen are based on the responses
of 3,608 people who were screened between
February and November of 2006. The
participants were seeking treatment from one of
four mental health centers, one of three
substance abuse treatment providers, or one of
two programs that treat people with a co-cooccurring disorder.
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The Psychometric Properties of the Screen
► The
process used to determine the psychometric
properties of this screen was first to verify that the
questions in each of the subscales (mental health and
substance abuse items) were conceptually related and
if they could be reduced in number.
► The Factor Analysis Extraction procedure helped
answer these questions. The Varimax rotated two
factor solution indicates that there are two clearly
separate conceptual dimensions and the number of
items in the two scales could not be reduced. The
factor solution also accounted for 57.25% of the
variance among those being screened.
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Screen Reliability
► Second,
Cronbach Alpha coefficients were used
as a statistical measure of the internal
consistency of each of the two subscales.
► The Cronbach Alpha for the Mental Health
screen was very good (α = .79).
► The Cronbach Alpha for the Substance Abuse
Screen was excellent (α = .89).
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Screen Sensitivity & Specificity
► Sensitivity and
specificity were examined
against the Client Assessment Record (CAR)
assessment, the Addiction Severity Index (ASI)
assessments, and the Axis I primary and
secondary diagnoses (see Tables 1 & 2). In this
population, the AC/OK Screen (which takes five
minutes to administer) agreed with the
CAR_substance abuse scale in 90.5% of cases
that the individual needed to be fully assessed
for a co-occurring disorder.
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Definition: Sensitivity and Specificity
► Sensitivity,
the fraction of those with the
mental health or substance abuse disorders
correctly identified by the screening tool
(Blume, 2002).
► Specificity, the fraction of those without a
mental health or substance abuse disorder
correctly identified by the screening tool
(Blume, 2002).
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Validity of the Screen
► The AC/OK
Screen agreement with the ASI
psychiatric scale was even more impressive.
The AC/OK Screen agreed with the ASI
psychiatric scale in 96% of the cases that the
individual needed a full assessment for a cooccurring disorder. Finally, the AC/OK Screen
(which takes five minutes to administer) agreed
with the DSM-IV diagnosis of a co-occurring
disorder in 91% of the cases.
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The Percentage of People Identified by
the AC-OK Screen
► The AC/OK
Screen identified approximately
72% of all people applying for treatment as
needing a full assessment to determine if the
person has a co-occurring disorder. This is
estimated to be as much as twice the number of
people who will be diagnosed with a cooccurring disorder after a full clinical assessment
for both a mental health and substance abuse
problem.
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5 Minutes Can Make a Difference
► What
difference can 5 minutes make to a person who
is seeking help for a co-existing disorder?
Determining that a person has a co-existing disorder
when he or she first asks for help can save an average
of four and a half years of that person’s life.
► In this data there is over a four year (4.4 yrs)
difference in the average age of people in this study
seeking treatment in a substance abuse treatment
program (32.87 yrs) and those seeking help from a
program providing treatment for a co-existing
disorder (37.31 yrs).
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Disadvantages
► People
with a co-occurring disorder are also
slightly more likely to be involved in the
criminal justice system. More people with a cooccurring disorder tend to enter treatment
struggling with suicidal ideations. They tend to
have more problems with substance abuse than
others entering treatment for addiction.
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Strengths on Which to Build a
Long Term Recovery
► Yet,
people with a co-occurring disorder are
likely to have fewer problems with psychoses
and anxiety disorders. They usually have a
higher level of education. And, they tend to be
more committed to treatment (based on the
percentage of voluntary admissions, and the high
number who complete treatment) (See:
http://faculty-staff.ou.edu/C/Andrew.L.Cherry1.Jr/AC-CODScreenPg.htm
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