enhancing co-occurring disorder services in addiction treatment: preliminary findings of the texas...

Enhancing Co-Occurring Disorder Enhancing Co-Occurring Disorder Services in Addiction Treatment:Services in Addiction Treatment:

Preliminary Findings of the Texas Preliminary Findings of the Texas Co-Occurring State Incentive Co-Occurring State Incentive

GrantGrant

Dartmouth Psychiatric Research Center SeminarDartmouth Psychiatric Research Center SeminarMay 2007May 2007

Texas COSIG Project Texas COSIG Project

The goal of the COSIG project is to improve The goal of the COSIG project is to improve the delivery of state-funded services for the delivery of state-funded services for clients in Texas with co-occurring psychiatric clients in Texas with co-occurring psychiatric and substance use disorders (COPSD).and substance use disorders (COPSD).

The project consists of two components The project consists of two components designed to promote system change and to designed to promote system change and to enhance specialized clinical skills of enhance specialized clinical skills of providers treating COPSD.providers treating COPSD.

COSIG Project Component #1COSIG Project Component #1

Focused education at the clinician level Focused education at the clinician level regarding treatment issues relevant to regarding treatment issues relevant to COPSD and training on the use of COPSD and training on the use of diagnostic and assessment instruments to diagnostic and assessment instruments to enhance identification of psychiatric enhance identification of psychiatric comorbidity and monitor progress of comorbidity and monitor progress of clients.clients.

COPSD Curriculum ModulesCOPSD Curriculum Modules

Module 1: Substance Use and Mental Health DisordersModule 1: Substance Use and Mental Health Disorders

Module 2: Depression and Substance Use DisordersModule 2: Depression and Substance Use Disorders

Module 3: Substance Use and Bipolar DisordersModule 3: Substance Use and Bipolar Disorders

Module 4: Anxiety and Substance UseModule 4: Anxiety and Substance Use

Module 5: Schizophrenia, Schizoaffective, and SubstanceModule 5: Schizophrenia, Schizoaffective, and Substance Use DisordersUse Disorders

Module 6: Substance Use – Motives and ConsequencesModule 6: Substance Use – Motives and Consequences

Module 7: Principles of TreatmentModule 7: Principles of Treatment

Module 8: Relapse Prevention Module 8: Relapse Prevention

Diagnostic and Assessment MeasuresDiagnostic and Assessment Measures

Mini International Neuropsychiatric Interview (MINI)Mini International Neuropsychiatric Interview (MINI)

Brief Symptom Inventory (BSI)Brief Symptom Inventory (BSI)

Brief Derogatis Psychiatric Rating Scale (BDPRS)Brief Derogatis Psychiatric Rating Scale (BDPRS)

Substance Abuse Treatment Scale (SATS)Substance Abuse Treatment Scale (SATS)

Ancillary Service AssessmentAncillary Service Assessment

Client Evaluation of Self in Treatment (CEST)Client Evaluation of Self in Treatment (CEST)

Counselor Comments on Use of Diagnostic Counselor Comments on Use of Diagnostic and Assessment Measuresand Assessment Measures

Repeated administration of the MINI has increased Repeated administration of the MINI has increased understanding of disorders and enhanced ability to understanding of disorders and enhanced ability to recognize potential symptomsrecognize potential symptoms

Using results of measures has assisted in “bridging a Using results of measures has assisted in “bridging a gap” by facilitating interactions with mental health gap” by facilitating interactions with mental health providersproviders

Administration can enhance client awareness of COD Administration can enhance client awareness of COD issues – many have never been asked these questions issues – many have never been asked these questions beforebefore

Results highlight issues to be addressed in sessions with Results highlight issues to be addressed in sessions with clients and provide a means to monitor progressclients and provide a means to monitor progress

COSIG Project Component #2COSIG Project Component #2

A voucher system that provides A voucher system that provides additional funding for procurement of additional funding for procurement of ancillary services in an effort to address ancillary services in an effort to address the multifaceted needs of COPSD clients the multifaceted needs of COPSD clients and to support the treatment and and to support the treatment and recovery process ($1,800 per client).recovery process ($1,800 per client).

Voucher Service CategoriesVoucher Service Categories

Child CareChild Care

Housing SupportHousing Support

TransportationTransportation

Food AssistanceFood Assistance

Education SupportEducation Support

Employment AssistanceEmployment Assistance

ClothingClothing

Medical CareMedical Care

PrescriptionsPrescriptions

Peer MentoringPeer Mentoring

Administration of Evaluation MeasuresAdministration of Evaluation Measures

CLINICIAN

CLIENT

Ancillary ServicesAssessment

BHIPS Termination

TERMINATION

BDPRS

SATS

BSI

Motivation & Treatment

FOLLOW-UP

60-Day FU

MONTHLYADMISSION

BHIPS Assessment

MINI Diagnostic

BDPRS

BHIPS

SATS

Motivation Scales

BHIPS Wrap-Around

BDPRS

BSIBSI

CEST Treatment

Assessment

SATS

Process ScalesProcess Scales

Ancillary Services

CEST TreatmentCEST TreatmentMotivation & Treatment

COSIG Treatment ProvidersCOSIG Treatment Providers

Lubbock Regional MHMR Center

Hill Country MHMR Center Montrose

Counseling Center

Fort Bend Council on Family and

Community Development, Inc.

Association for the Advancement of

Mexican Americans, Inc.

Homeward Bound, Inc.

Nexus Recovery Center, Inc. --AND--Homeward Bound, Inc.

Northeast Texas Council on Alcoholism and Drug Abuse

Central Texas Council on Alcoholism and Drug Abuse

Santa Maria Hostel, Inc

Program Summary Program Summary ReportsReports

Psychiatric Diagnostic Impressions Psychiatric Diagnostic Impressions Program X and COSIG StatewideProgram X and COSIG Statewide

(Data through March 2007)(Data through March 2007)

64%

30%

2%

11%

26%

30%

41%

3%

28%

49%

38%

3%

11%

22%

29% 28%

7%

41%

BIPOLAR DEPRESSION HYPOMANIC DYSTHYMIA PANIC OCD PTSD PSYCHOTIC GEN ANXIETY

PROGRAM X (N = 116) COSIG STATE (N = 786)

Substance Use DisordersSubstance Use DisordersProgram X and COSIG StatewideProgram X and COSIG Statewide


18%

33%

49%

14%

37%

50%

ALCOHOL ONLY DRUG ONLY ALCOHOL AND DRUG


s

BSI Scores in the Clinically Significant RangeBSI Scores in the Clinically Significant RangeProgram X and COSIG StatewideProgram X and COSIG Statewide


24%

22%

12%13%

21%

10%

18%

12%10%

22%

28%

21%

17%

13%15% 15%

18%

22%

19%

28%

SOM OC IS DEP ANX HOS PHOB PAR PSY GSI


BDPRS Ratings in the Marked to Extreme RangeBDPRS Ratings in the Marked to Extreme RangeProgram X and COSIG StatewideProgram X and COSIG Statewide


28%

42%

50%

46%44%

7%5%

9%

3%

55%

21%19%

32%35%

32%

9%

13% 14%10%

25%

SOM OC IS DEP ANX HOS PHOB PAR PSY GPI

Program X (N = 115) COSIG STATE (N = 756)

BSI and BDPRS Scores in the Clinically Significant RangeBSI and BDPRS Scores in the Clinically Significant RangeProgram X (N = 115)Program X (N = 115)


24%22%

12% 13%

21%

10%

18%

12%10%

22%

28%

42%

50%

46%44%

7%5%

9%

3%

55%


BSI Client Self-Report BDPRS Clinician Ratings

BDPRS and BSI Scores in the Clinically Significant RangeBDPRS and BSI Scores in the Clinically Significant RangeCOSIG Statewide (N = 756)COSIG Statewide (N = 756)


28%

21%

17%

13%15% 15%

18%

22%

19%

28%

21%

19%

32%

35%

32%

9%

13% 14%

10%

25%


BSI Client Self-Report BDPRS Clinician Ratings

SATS Ratings at Admission to COSIGSATS Ratings at Admission to COSIGProgram X and COSIG StatewideProgram X and COSIG Statewide


1%

7%

24%

9%

34%

22%

3%

0%1%2%

35%

13%

20%23%

6%

0%

Pre-Engagement

Engagement EarlyPersuasion

LatePersuasion

Early ActiveTreatment

Late ActiveTreatment

RelapsePrevention

In Remissionor Recovery


BSI Scale Averages at Admission and One Month in COSIGBSI Scale Averages at Admission and One Month in COSIGProgram X (N = 47)Program X (N = 47)


40

45

50

55

60


ADMISSION ONE MONTH IN COSIG

BDPRS Averages at Admission and One Month in COSIGBDPRS Averages at Admission and One Month in COSIGProgram X (N = 47)Program X (N = 47)


0

1

2

3

4

5

6



BSI Scores in the Clinically Significant Range BSI Scores in the Clinically Significant Range at Admission and One Month in COSIGat Admission and One Month in COSIG

Program X (N = 47)Program X (N = 47)(Data through March 2007)(Data through March 2007)

19%

26%

9%

6%

17%

13%

19%

11% 11%

13%

9%

13%

4% 4%

6%

9%

6%

11%

13%

9%



BDPRS Ratings in the Marked to Extreme Range BDPRS Ratings in the Marked to Extreme Range at Admission and One Month in COSIGat Admission and One Month in COSIG


30%

34%

62%

47%

40%

11%

6%9%

4%

48%

15%

43%

60%

32%30%

2%4%

11%

2%

36%



SATS Ratings at Admission and One Month in COSIGSATS Ratings at Admission and One Month in COSIGProgram X (N = 47)Program X (N = 47)


2%4%

11%9%

38%

30%

6%

0%0%2% 2%

0%

23%

62%

11%

0%

Pre-Engagement

Engagement EarlyPersuasion

LatePersuasion

Early ActiveTreatment

Late ActiveTreatment

RelapsePrevention

In Remissionor Recovery


Voucher Services Needed and Received Voucher Services Needed and Received at One Month in COSIG (Client Report)at One Month in COSIG (Client Report)


0%

79%

5%

15%

0%

5%

2%

36%

21%

2%

5%

84%

7%

24%

14%

12%

7%

47%

28%

21%

Child Care

Housing Support

Transportation

Food Assistance

Education Support

Employment Assistance

Clothing

Medical Care

Prescriptions

Peer Mentoring

RECEIVED SERVICE NEEDED SERVICE

Programs Value Regular FeedbackPrograms Value Regular Feedback

Provider reported uses of data reports:Provider reported uses of data reports:

Internal monitoring of COSIG program implementationInternal monitoring of COSIG program implementation

Greater understanding of COD client characteristics and Greater understanding of COD client characteristics and individual needs to guide programmingindividual needs to guide programming

Board of Directors and Executive Management Team Board of Directors and Executive Management Team presentationspresentations

Presentations to other community service providers to Presentations to other community service providers to enhance networking (i.e., probation department, enhance networking (i.e., probation department, homeless alliances, planning and advisory committees)homeless alliances, planning and advisory committees)

Data for grant and other funding applicationsData for grant and other funding applications

Preliminary OutcomesPreliminary Outcomes

Client and Service Client and Service Characteristics Associated Characteristics Associated with Treatment Completionwith Treatment Completion

COSIG Client OutcomesCOSIG Client Outcomes

Data were obtained for 424 COSIG clients who Data were obtained for 424 COSIG clients who entered and were discharged from substance entered and were discharged from substance abuse treatment during the period of February abuse treatment during the period of February 2005 through October 20062005 through October 2006

76% of the sample completed treatment76% of the sample completed treatment

Treatment completers (n=323) and non-Treatment completers (n=323) and non-completers (n=101) were compared on client completers (n=101) were compared on client and service characteristicsand service characteristics

Client DemographicsClient Demographics

Treatment completers were more likely to Treatment completers were more likely to be male (51% vs. 34%) and homeless be male (51% vs. 34%) and homeless (24% vs. 14%)(24% vs. 14%)

The groups did not differ in race/ethnicity, The groups did not differ in race/ethnicity, education, age, marital status, education, age, marital status, employment, or past year substance-employment, or past year substance-related arrestsrelated arrests

MINI Diagnostic ImpressionsMINI Diagnostic Impressions

0%

10%

20%

30%

40%

50%

60%

BIPOLAR DEPRESSION HYPOMANIC DYSTHYMIA PANIC OCD PSYCHOTIC GENANXIETY

PTSD

COMPLETER NON-COMPLETER

*

**

*

Psychiatric Symptom SeverityPsychiatric Symptom Severity

No differences were found in client-No differences were found in client-reported symptom severity on the Brief reported symptom severity on the Brief Symptom Inventory scalesSymptom Inventory scales

Clinicians rated non-completers as having Clinicians rated non-completers as having more severe symptoms on the more severe symptoms on the interpersonal sensitivity, depression, and interpersonal sensitivity, depression, and hostility scales on the Brief Derogatis hostility scales on the Brief Derogatis Psychiatric Rating ScalePsychiatric Rating Scale

Primary Substance of AbusePrimary Substance of Abuse

0%

5%

10%

15%

20%

25%

30%

35%

40%

ALCOHOL COCAINE CRACK OPIATES MARIJUANA OTHER


Substance Use PatternsSubstance Use Patterns

Completers reported a greater primary Completers reported a greater primary substance use during the month prior to substance use during the month prior to admission (15 vs.12 days)admission (15 vs.12 days)

A greater percentage of non-completers A greater percentage of non-completers reported polysubstance use (56% vs. 42%)reported polysubstance use (56% vs. 42%)

No differences were found in total years of No differences were found in total years of primary substance use or history of IV drug useprimary substance use or history of IV drug use

Substance Abuse Treatment HistorySubstance Abuse Treatment History

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

PRIOR DETOX PRIOR NON-DETOX AA PAST 30 DAYS

COMPLETERS NON-COMPLETERS

*

*

*

Discharge CharacteristicsDischarge Characteristics

Completers had higher past month Completers had higher past month abstinence rates (88% vs. 61%)abstinence rates (88% vs. 61%)

Completers had higher past month AA Completers had higher past month AA attendance (95% vs. 78%)attendance (95% vs. 78%)

No group differences were found in length No group differences were found in length of stay in treatment (approximately 100 of stay in treatment (approximately 100 days)days)

Voucher Service UtilizationVoucher Service Utilization

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

CHILDCARE

VOCATIONAL

PRESCRIPTIONS

MEDICAL

CLOTHING

EDUCATION

PEER MENTORING

FOOD

TRANSPORTATION

HOUSING


**

*

*

*

Recovery and Social Support Recovery and Social Support Service CombinationsService Combinations

0%

10%

20%

30%

40%

50%

60%

70%

PEER MENTORING AND SOCIAL SUPPORT SOCIAL SUPPORT ONLY


*

*

ConclusionsConclusions

Higher treatment completion for males indicates Higher treatment completion for males indicates that women with COD may need specialized that women with COD may need specialized interventions in substance abuse treatmentinterventions in substance abuse treatment

A study analyzing gender differences using a A study analyzing gender differences using a subset of these data revealed that women subset of these data revealed that women demonstrated higher awareness of psychiatric demonstrated higher awareness of psychiatric issues relative to substance abuse problems, issues relative to substance abuse problems, suggesting that substance abuse treatment suggesting that substance abuse treatment inventions may need greater focus on the inventions may need greater focus on the interaction of the two disorders* interaction of the two disorders*

*(Mangrum, Spence, & Steinley-Bumgarner, 2006)*(Mangrum, Spence, & Steinley-Bumgarner, 2006)


Lower completion rates for clients with Lower completion rates for clients with bipolar and posttraumatic stress disorders bipolar and posttraumatic stress disorders suggest that these syndromes may be suggest that these syndromes may be more difficult to treat in substance abuse more difficult to treat in substance abuse treatment settings treatment settings

Substance abuse counselors may need Substance abuse counselors may need training on specific interventions targeting training on specific interventions targeting these two disordersthese two disorders


The 76% completion rate for the total sample is higher The 76% completion rate for the total sample is higher than previously calculated statewide averages, than previously calculated statewide averages, suggesting that the provision of recovery and social suggesting that the provision of recovery and social support services may enhance treatment outcomessupport services may enhance treatment outcomes

A study examining clients receiving COPSD services in A study examining clients receiving COPSD services in Texas during FY 2004 revealed a 57% completion rate* Texas during FY 2004 revealed a 57% completion rate*

Other analyses of general substance abuse treatment Other analyses of general substance abuse treatment clients in Texas have indicated completion rates ranging clients in Texas have indicated completion rates ranging from 51 - 54% from 51 - 54%

*(Mangrum & Spence, 2005)*(Mangrum & Spence, 2005)


Peer mentoring had the strongest association Peer mentoring had the strongest association with treatment completionwith treatment completion

Social support services, particularly in the Social support services, particularly in the absence of peer mentoring, were associated absence of peer mentoring, were associated with non-completionwith non-completion

Similar trends have been found in the Texas Similar trends have been found in the Texas ATR voucher service data, indicating that direct ATR voucher service data, indicating that direct recovery support services are associated with recovery support services are associated with greater completion rates, whereas the provision greater completion rates, whereas the provision of social support services only is more highly of social support services only is more highly associated with non-completionassociated with non-completion

DDCAT AssessmentsDDCAT Assessments

Preliminary ResultsPreliminary Results

Overall DDCAT ScoresOverall DDCAT Scores

2.69

4.57

3.273.05

3.41

2.89

3.19

A1 A2-OP A2-R A3-OP A3-R A4 A5

DDE: 5

DDC: 3

AOS: 1

Dual Diagnosis Capability ClassificationsDual Diagnosis Capability Classifications

DDC 3

AOS 4

DDE 1

DDC 4

AOS / DDC 2

Criterion Method Scoring Scale Method Scoring

DDCAT Scale Scores by ProgramDDCAT Scale Scores by Program

A1

A2-OP

A2-R

A3-0P

A3-R

A4A5

PS PM CP:A CP:T CC S T

DDE: 5

DDC: 3

AOS: 1

Average DDCAT Scale Scores StatewideAverage DDCAT Scale Scores Statewide

PS PM CP:A CP:T CC S T

DDE: 5

DDC: 3

AOS: 1

enhancing co-occurring disorder services in addiction treatment: preliminary findings of the texas...

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substance use module

substance use disorders

substance use disorders

use of diagnostic

substance use motives

principles of treatment

bipolar disorders module

treatment cest slide