Transcript TIP 42 (and Beyond) — Substance Treatment for Persons with

TIP 42 (and Beyond) —
Substance Treatment for Persons
with Co-Occurring Disorders
Stanley Sacks, Ph.D.,
Center for the Integration of Research & Practice
National Development & Research Institutes, Inc.
European Federation of Therapeutic Communities Conference
Ljubljana, Slovenia ► June 2007
SAMHSA’s Definition of
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.
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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Co-Occurring Mental and
Substance Use Disorders
Mental
Disorders
A
C
B
Substance
Use
Disorders
Adapted from Osher, F.C. (1996)
3
COD & Treatment Outcomes
COD clients have poorer outcomes, such as
higher rates of HIV infection, relapse,
rehospitalization, depression and suicide risk.
COD clients have better outcomes with
treatment designed for their special needs.
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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COD Advances Timeline
1979
Woody &
Blaine
Substance
Abuse &
Depression
Mid
1990’s
Sacks &
De Leon
MTC
1981
Pepper
Chronic
Young Adult
1989
1993
Early 1990’s
Mid 1990’s
Minkoff
Integrated
Treatment
Ries
Kessler
Drake
TIP 9
National
Comorbidity
Survey
ACT
1996-7
Late 1998
1999
DATOS
Studies
EvidencedBased
Practices
for SMI
NASADAD
NASMPHD
Four
Quadrants
20002003
2002Pres.
Research on
Strategies &
Models
TIP 42
Report to Congress
Co-Occurring Center
for Excellence
State Initiatives
Toolkits
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Prevalence of Co-Occurring Disorders
mental health programs1
clients with
substance use disorder
20% — 50%
drug treatment facilities1
clients with
mental disorder (most not severe)
50% — 75%
General Population (National Comorbidity Survey )
2
of those with
lifetime addictive disorder
of those with
lifetime mental illness disorder
50%
50%
have mental
disorder
have substance
use disorder
Over 4 million with serious mental disorders3
Source:
1 Sacks et al. 1997; 2 Kessler, R. et al. 1994; 3 Grant et al. 2004; SAMHSA, 2004
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High Severity
The Four Quadrants
III
Less severe mental
disorder/more severe
substance abuse
disorder
IV
More severe mental
disorder/more severe
substance abuse
disorder
I
Less severe mental
disorder/less severe
substance abuse
disorder
II
More severe mental
disorder/less severe
substance abuse
disorder
Low Severity
Mental Illness
High Severity
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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The Clinical Planning Process
Assessment
Screening
Diagnosis
Person
Treatment Services
(referral or provision)
Individualized
Treatment Plan
Developing Treatment
Resources
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Screening
Definition
Screening is a formal process of testing to determine whether
or not a person has a disorder that warrants further attention
at the time of testing and, within this context, to determine
whether or not a co-occurring substance use or mental
disorder may be present (Center for Substance Abuse
Treatment [CSAT], 2005a; 2005b).
The screening process for co-occurring disorders seeks to
answer a “yes” or “no” question: Does the client with a
substance use [or mental] disorder show signs of a possible
mental [or substance use] disorder?
The screening process does not necessarily identify the type
or the severity of the disorder, but determines only whether or
not the person has a disorder and indicates when additional
assessment is needed.
Source: CSAT 2005a, b
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Features of Screening Instruments
High sensitivity
Brief
Low cost and no cost
Minimal staff training required
Consumer friendly
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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Measures of Precision Defined
Sensitivity: the probability that the screening test is positive
given that the person has the disorder. This is also know as the
true positive rate. A large sensitivity means that a negative test
can rule out the disorder.
Specificity: the probability that the screening test is negative
given that the person does not have the disorder. This is also
known as true negative rate . A large specificity means that a
positive test can rule in the disorder.
Overall Accuracy: is the combination of sensitivity and
specificity – the probability that the screening test is positive
given that the person has the disorder combined with the
probability that the screening test is negative given that the
person does not have the disorder.
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Validation Results –
Any Mental Disorder
Instrument
Sensitivity
Specificity
Overall
Accuracy
78.8%
47.7%
72.6%
84.9%
45.5%
77.1%
67.6%
52.3%
64.6%
83.8%
36.4%
74.4%
CODSI-MD
Score of 3 or higher
MHSF
Score of 3 or higher
M.I.N.I.
Score of 5 or higher
GSS
Score of 2 or higher
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Counselor Role in Screening
In substance abuse or mental health treatment
settings, every counselor or clinician who conducts
intake should be able to screen for the most common
COD and know how to implement the protocol for
obtaining COD assessment information and
recommendations.
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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List of Screening Instruments
Mental Disorder Screening Instruments:
The Mental Health Screening Form-III (MHSF)-III
Mini-International Neuropsychiatric Interview (M.I.N.I.)
M.I.N.I. Screen Modified
National Center for Health Statistics - 10 Questions (K10)
Referral Decision Scale (RDS)
Substance Use Disorder Screening Instruments
CAGE Questionnaire Adapted to Include Drugs (CAGE-AID)
Dartmouth Assessment of Lifestyle (DALI)
DALI Screen Modified (NYS)
Drug Abuse Screening Test (DAST)
Short Alcohol Dependence Data Questionnaire (SADD)
Simple Screening Instrument for Substance Abuse (SSI-SA)
TCU-Drug Screen II (TCUDS)
Substance Use and Mental Disorder Screening Instrument
Alcohol Dependence Scale (ADS)
Global Appraisal of Individual Needs (GAIN)
GAIN - Quick (GAIN-Q)
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COCE Recommendations for a
Selection Process
1.
Screening Instruments in the Matrix review are all acceptable.
2.
Decide if you want a screening instrument for substance use disorder, a
screening instrument for mental disorders or both.
3.
If the latter, either use a combination of SA and MH screening
instruments (for example, MINI Screen Modified/DALI) or use the GAIN.
4.
COCE recognizes that the use of other instruments may be desirable in
a particular circumstance and that there are other viable options
available.
5.
Consider customizing your instrument with additional items selected
from the comprehensive list of instruments.
6.
Involve stakeholders and users in the instruments selection process.
7.
Begin parallel development of coordinated assessment instruments,
placement determination, treatment planning and treatment resources.
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Assessment
Definition
Gathers information and engages in a process with the
client that enables the provider to establish (or rule
out) the presence or absence of a co-occurring
disorder.
Determines the client’s readiness for change, identifies
client strengths or problem areas that may affect the
processes of treatment and recovery, and engages the
client in the development of an appropriate treatment
relationship.
Source: CSAT 2005b.
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Basic Assessment Consists of:
Background
Substance use
Psychiatric problems
Integrated assessment
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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List of Selected Assessment Instruments
Substance Abuse
Addiction Severity Index (ASI)
Global Appraisal of Individual Needs (GAIN)
Individual Assessment Profile (IAP)
Mental Health
Beck Depression Inventory–II (BDI–II)
Beck Hopelessness Scale (BHS)
Brief Psychiatric Rating Scale (BPRS)
Brief Symptom Inventory (BSI)
General Behavioral Inventory (GBI)
Referral Decision Scale (RDS)
Trauma Informed
Post-traumatic Stress Symptom Scale Self Report (PSS-SR)
Trauma History Questionnaire (THQ)
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List of Selected Assessment Instruments Continued
General Health
— Medical Outcomes Study Short Form (SF-36)
Diagnostic
— Diagnostic Interview Schedule (DIS-IV)
— Structured Clinical Interview for DSM-IV Disorders (SCID)
Motivation and Readiness to Change
— Circumstances, Motivation, and Readiness Scales (CMR Scales)
— Readiness to Change Questionnaire
— Stages of Change, Readiness and Treatment Eagerness Scale
(SOCRATES)
— University of Rhode Island Change Assessment (URICA)
— Recovery Attitude and Treatment Evaluator (RAATE)
Level of Care
— Level of Care Utilization System (LOCUS)
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Additional Considerations
Assessment should be a clinical driven processinvolves clinician making connection with the
client.
Consider the client in a context (i.e. setting) and
fit assessment process to the setting.
Take into account the system of care the person
is in – think of systems available so you can do
treatment planning.
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Advice to the Counselor:
Do’s and Don’ts of Assessment for COD
Do keep in mind that assessment is about getting to know a person with
complex and individual needs. Do not rely on tools alone for a comprehensive
assessment.
Do always make every effort to contact all involved parties.
Don’t allow preconceptions about addiction to interfere with learning about
what the client really needs.
Do become familiar with the diagnostic criteria for common mental disorders,
including personality disorders, and with the names and indications of
common psychiatric medications.
Don’t assume that there is one correct treatment approach or program for any
type of COD.
Do become familiar with the specific role that your program or setting plays in
delivering services related to COD in the wider context of the system of care.
Don’t be afraid to admit when you don’t know, either to the client or yourself.
Most important, do remember that empathy and hope are the most valuable
components of your work with a client.
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP #42 (2005a)
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Treatment Planning
Definition
Develops a comprehensive set of staged, integrated
program placements and treatment interventions for
each disorder that is adjusted as needed to take into
account issues related to the other disorder.
The plan is matched to the individual needs,
readiness, preferences, and personal goals of the
client.
Source: CSAT 2005b
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What is an Evidence-Based Practice?
In the area of COD treatment, EBP is defined by COCE
primarily as the use of current and best research evidence in
making clinical and programmatic decisions about services to
client[s). The research considerations involved in
determining what constitutes an evidence-based practice
include not only the robustness of the study findings but also
the type of design employed and the methodological rigor of
the procedures.
A broader definition of EBP also includes taking into account
clinician expertise and patient values, as indicated by
the Institute of Medicine (2000) and more recently by the
American Psychological Association (2005).
Center for Substance Abuse Treatment. (2005c)
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Pyramid of Evidence Based Practices
in COD: Type of Design
Center for Substance Abuse Treatment. (2005c)
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Quality of the Research
Sample Representativeness
Psychometric Features of Interview Instruments
Appropriateness of Analytic Techniques
Robustness of the Findings
Threats to Validity
25
Readiness for Dissemination
Curriculum
Training
Technical Assistance
Supervision
Quality Assurance of Fidelity
26
Table of Consensus- and Evidence-Based Practices for COD
Evidence-Based Practices
for COD
Consensus-Based
Principles for COD
Services
Consensus-Based
COD Program
Components
Evidence-Based
Practices from
Substance Abuse
Treatment
Employ a recovery
perspective
Screening,
assessment, and
referral
Motivational enhancement
Medical management
approaches in psychiatry
Group Counseling
Adopt a multi-problem
viewpoint
Psychiatric and mental
health consultation
Cognitive-behavioral therapy
Family Psychoeducational
Contingency Management
Develop a phased approach
to treatment
Intensive case
management
Relapse prevention
Supported employment
Long-Term Residential
(including Modified TC’s)
Address specific real-life
problems early in treatment
Prescribing on-site
psychiatrist
Illness management and
recovery skills
For Other Outcomes (but not
substance abuse)
Plan for the client’s cognitive
and functional impairments
Medication and
medication monitoring
Assertive Community
Treatment
Case Management (including
both Assertive Community
Treatment and Intensive Case
Management)
Psychoeducational
classes
Integrated Dual Disorder
Treatment
Legal Interventions
Use support systems to
maintain and extend
treatment effectiveness
Expect co-occurring
disorders and reflect that
assumption in screening,
assessment, and treatment
planning
Consider both substance use
and mental disorders as
equally important
Individualize treatment plans
to accommodate specific
needs and personal goals of
clients
Evidence-Based
Practices from Mental
Health1
For Substance Abuse and
Other Outcomes (mostly
those with severe mental
disorders)2
Double recovery
groups
1
The last two in this column are specific to those with co-occurring disorders.
Based on Drake, R., O’Neal, E.L., & Wallach, M.A. A systematic review of research on
interventions for people with co-occurring severe mental and substance use disorders. Journal
of Substance Abuse Treatment, (in press).
2
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Modified TC
Key Modifications
to structure
more flexible activities
shorter meetings &
activities
to process
to elements
fewer sanctions
engagement emphasis
accent on orientation &
instruction
more staff
individually paced
progress in program
individualized task
assignments
responsibility as role
models
flexible criteria for
moving to next stage
engagement emphasis
throughout
live-out re-entry
(aftercare) essential
activities proceed at a
slower pace
more staff guidance
counseling to assist use
of community
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP, 2005a
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Summary
The Modified TC is
more flexible
less intense
more individualized
The quintessential elements remain
peer self-help
community-as-method
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP, 2005a
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Outcomes baseline vs 2-year follow-up
3.5
3
Modified TC2
TAU
2.5
2
1.5
1
0.5
0
De Leon, G., Sacks, S., et al. 2000.
baseline
2-year
follow-up
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Benefit Cost Analysis
incremental benefit of modified TC
$273,115
cost per client of modified TC treatment
$20,361
total net benefit per client ($273,115 - $20,361)
$252,114
Benefit cost ratio $252,114/$20,361 =
(13:1— data winsorized 6:1)
$6 benefit for every $1 of cost
Source: French, M., McCollister, K., Sacks, S. et al 2002.
$6
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MICA Offender 12 Month Outcomes
50
reincarceration
rates
40
30
33%
20
MH
10
16%
TC only
TC +
aftercare
5%
0
Total n= 139
n=64
n=32
n=43
Sacks, S., Sacks, J., et al. 2004
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Substance Abuse
Illegal Drug Use (P<.05)
100%
80%
79%
86%
60%
40%
44%
20%
25%
0%
Baseline
MTC Total (n=75)
12M PP
MH (n=64)
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MTC for Co-Occurring Disorders:
A Meta-Analysis of Three Studies (Four Comparisons)
Summary of meta-analysis combined study comparisons —
random effects analysis (differential treatment effects: MTC vs. Comparison)
Domain
Effect Size
Odds
Ratio†
95% CI
p
Q (p)
I2
Substance abuse
0.650
(0.428 –
0.986)
.043*
4.998(0.172)
39.977
Mental health
0.679
(0.478 –
0.966)
.031*
2.026(0.567)
0.000
Crime
0.662
(0.454 –
0.966)
.032*
2.573(0.462)
0.000
HIV-risk behavior
1.007
(0.659 –
1.539)
.974
3.068(0.381)
2.225
Employment
0.404
(0.251 –
0.651)
.000***
6.351(0.096)
52.761
Housing
0.634
(0.420 –
0.958)
.030*
0.370(0.946)
0.000
*p<0.05; **p<0.01; ***p<0.001
† An odds ratio less than one indicates a greater improvement for clients in the MTC group than in the comparison group.
Source: Sacks, Banks, McKendrick et al 2007
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Advice to Counselors & Administrators:
Recommended Treatment and Services From the MTC Model
Treat the whole person.
Provide a highly structured daily regimen.
Use peers to help one another.
Rely on a network or community for both support and healing.
Regard all interactions as opportunities for change.
Foster positive growth and development.
Promote change in behavior, attitudes, values, and lifestyle.
Teach, honor, and respect cultural values, beliefs, and differences.
Adapted from Substance Abuse Treatment for Persons With Co-Occurring Disorders TIP 42, 2005a
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Services Integration and
Other Forms of Integration
Providing Integrated
Treatment to Clients is
Fundamental
Without this, Integrated
Programs and Systems
Integration have no purpose
Integrated Programs
can facilitate
Integrated Treatment
Services Integration
COD CLIENT
Integrated
Treatment
Integrated
Programs
Systems Integration
Systems Integration can facilitate Integrated
Treatment and Integrated Programs
Center for Substance Abuse Treatment, (2005d)
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COD Enhanced
Advanced
COD Capable
Intermediate
More Tx for Mental Disorders
Intermediate
COD Capable
Substance
Abuse Tx
COD Integrated
Advanced
Addiction Only Tx
Fully Integrated
COD Enhanced
Beginning
Levels of Program Capacity in COD
Mental Health
Tx
More Tx for Substance Abuse Disorders
Adapted from CSAT, 2005a, Substance Abuse Treatment for Persons With Co-Occurring Disorders, TIP 42
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Principles That Guide Provider
Activity For People With COD
Co-occurring disorders must be expected and treatment
approaches should incorporate this assumption in all
screening, assessment and treatment planning.
Within the treatment context, both co-occurring disorders
are considered of equal importance1.
Empathy, respect, and the belief in the individual’s
capacity for change are fundamental provider attitudes.
Treatment should be individualized to accommodate the
specific needs and personal goals of unique individuals in
different stages of change.
Center for Substance Abuse Treatment. 2005e
1Adapted
from original
38
Building Blocks for Constructing a
Co-Occurring Treatment System
Clinical Capacity
Evaluation and Monitoring
Infrastructure
Information Sharing
Evidence and Consensus- Based Practices
Certification and Licensure
Workforce Development and
Training
Financing Mechanisms
Screening, Assessment, &
Treatment Planning
Definitions, Terminology,
Classification
Systems Change
Services Integration
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Conclusion
Much has been accomplished in the field of COD in the last 10 years, and
the knowledge acquired is ready for broader dissemination and application.
The importance of the transfer and application of knowledge and
technology has likewise become better understood.
New government initiatives (for example, COSIG, COCE, and MHT) are
underway that improve services by promoting innovative technology
transfer strategies using material that reflect the recent advances in the
field.
Source: Center for Substance Abuse Treatment. 2005a
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References
Center for Substance Abuse Treatment. 2005a. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment
Improvement Protocol (TIP) Series, Number 42. DHHS Pub. No. (SMA) 05-39920. Rockville, MD: Substance Abuse and Mental
Health Services Administration.
Center for Substance Abuse Treatment (CSAT). (2005b) Screening, Assessment, and Treatment Planning. Co-Occurring Center for
Excellence (COCE) Overview Paper No. 2. DHHS Publication No. (SMA) XX-XXXX. Rockville, MD: Substance Abuse and
Mental Health Services Administration (SAMHSA), and Center for Mental Health Services (CMHS). Retrieved online 09/08/06 at
http://coce.samhsa.gov/cod_resources/index_right_2.aspx?obj=77.Center for Substance Abuse Treatment. 2005d. Services
Integration. COCE Overview Paper. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Center for Substance Abuse Treatment. 2005c. The Use of Evidence- and Consensus-Based Practices in Treating Persons With CoOccurring Disorders. COCE Overview Paper No. 4. Rockville, MD: Substance Abuse and Mental Health Services
Administration.
Center for Substance Abuse Treatment. 2005d. Services Integration. COCE Overview Paper. Rockville, MD: Substance Abuse and
Mental Health Services Administration.
Center for Substance Abuse Treatment. 2005e. Overarching Principles in the Planning, Implementation, and Delivery of Service for
Persons with Co-Occurring Disorders. COCE Overview Paper. Rockville, MD: Substance Abuse and Mental Health Services
Administration.
De Leon, G., Sacks, S., Staines, G., & McKendrick, K. 2000. Modified therapeutic community for homeless MICAs: Treatment
Outcomes. American Journal of Drug and Alcohol Abuse, 26(3), 461-480.
Drake, R., O'Neal, E.L., & Wallach, M.A. (2007) A Systematic Review of Research on Interventions for People with Cooccurring Severe Mental and Substance Use Disorders. Journal of Substance Abuse Treatment, special issue,
accepted for publication.
French, M.T, McCollister, K.E., Sacks, S., McKendrick K. & De Leon, G. 2002. Benefit-cost analysis of a modified TC for mentally ill
chemical abusers. Evaluation and Program Planning, 25(2), 137-148.
CSAT/SAMHSA COCE OVERVIEW PAPERS CAN BE DOWNLOADED AT http://coce.samhsa.gov/
References
Grant, B.F., Stinson, F.S., Dawson, D.A., Chou, S.P., Dufour, M.C., Comptom, W., Pickering, R.P. & Kaplan,
K. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety
disorders. Archives of General Psychiatry, 61, 807–816, 2004.
Kessler, R.C., McGonagle, K., Zhao, S., Nelson, C.D., Hughes, M., Eshleman, S., Wittchen, H., and
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Mueser, K.T., Torrey, W.C., Lynde, D., Singer, P., & Drake, R.E. 2003. Implementing evidence-based
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Sacks, S., Sacks. J.Y., De Leon, G., Bernhardt, A.I. & Staines. G.L. 1997. Modified therapeutic community
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Substance Use and Misuse, 32(9), 1217-1259.
Sacks, S., Sacks, J.Y., McKendrick, K., Banks, S., & Stommel, J. 2004. Modified TC for MICA Offenders:
Crime Outcomes. Behavioral Sciences & The Law, 22, 477-501.
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Co-Occurring Disorders: A Research Synthesis Using Meta Analysis. Submitted to the American
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Contact information
Stanley Sacks, Ph.D.
Director, Center for the Integration of Research & Practice
National Development & Research Institutes, Inc.
71 W 23rd Street, 8th Floor
New York, NY 10010
tel 212.845.4429  fax 212.845.4650
http://www.ndri.org  [email protected]
European Federation of Therapeutic Communities Conference
Ljubljana, Slovenia ► June 2007
43