“Breaking Down the Silos” Integrated Dual Disorder Treatment (IDDT) Michael J. Biscaro, Psy.D., ABPP VA Recovery Resource Center (PRRC) Patrick Boyle, PH.D., LISW-S, LICDC-CS CWRU Center for Evidence Based Practices David Ditullio, LISW-S & Alisa Sprague, LISW-S VA Intensive Case Management (MHICM)

Scope of the Problem Substance abuse more common among people with severe mental disorders (schizophrenia, schizoaffective, bipolar, major depression w/ psychosis) About 50% people with SMI develop substance abuse disorders at some point

Prevalence of substance use disorders in mental illness This graph shows the percentage of people surveyed who had a substance use disorder. The bar on the left shows that about 15% of people in the general population had a substance use (alcohol or drug) disorder at some time in their life. The next bar show that almost 50% of people with schizophrenia had a substance use disorder and the next bar shows that people with bipolar disorder had even higher rates. The final three bars show that a quarter to a third of people with milder mood and anxiety disorders also have a substance use disorder at some time in their life.

Co-occurring conditions are common 73% of persons with a drug dependence disorder in substance abuse treatment had a co-occurring mental disorder at some point during their lifetime In substance abuse settings, very common to see: Major Depressive Disorder (and other mood disorders) Post-Traumatic Stress Disorder SOURCE: “The Epidemiology of Co-Occurring Substance Use and Mental Disorders.” COCE Overview Paper 8. DHHS Publication No. (SMA) 07-4308. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007.

SAMHSA Findings (Ries, 1994) Compared with clients with a single diagnosis, persons with co-occurring disorders experience: More severe and chronic medical, social and emotional problems Increased vulnerability to AOD relapse Greater risk of decompensation with relapse and vice versa Slide adapted from Delos-Reyes, Biscaro, Sprague 2013

SAMHSA Findings (Ries, 1994) Compared with clients with a single diagnosis, persons with co-occurring disorders experience: Require relapse prevention models designed to their diagnoses Require longer treatment Have more crises Progress more gradually in treatment Slide adapted from Delos-Reyes, Biscaro, Sprague 2013

When Dual Disorders are Present Ruling out dual diagnosis should be the expectation, not the exception Both Diagnoses should be considered primary Simultaneous treatment is required From: Minkoff, K. (2000). An Integrated Model for the Treatment of People with Co-Occurring Psychiatric and Substance Abuse Disorders. The Mental Illness Education Project, Inc.

When Dual Disorders are Present Typical Addiction treatment requires modification for individuals with psychiatric disorders Typical Mental health treatment requires modification for individuals with substance disorders Adapted from: Minkoff, K. (2000). An Integrated Model for the Treatment of People with Co-Occurring Psychiatric and Substance Abuse Disorders. The Mental Illness Education Project, Inc.

Traditional treatment Treats each disorder separately Parallel—occurs in the same time frame but at separate agencies or programs Sequential—occurs at different times, in the same or separate agencies/programs Typically treated by different staff, who have differing types of training Separate treatment is NOT effective

The Economic Cost of Not Integrating Treatment Continuous, repetitive cycling through the most expensive, publicly funded resources in the system: Hospitals Emergency/crisis services Detoxification Inpatient treatment Jails Demoralization of treatment professionals - staff attraction, retention, and turnover Breakdown of treatment systems

The Human Cost of Not Integrating Treatment Because of the cyclical nature and course: Much less improvement will be seen Potential for more productive participation in community life will be permanently lost

Why integrated treatment of dual disorders? More effective than separate treatment At least 45 controlled studies show integrated treatment is more effective than traditional treatment Drake, O’Neal, Wallach (2008). A systematic review of psychosocial interventions for people with co-occurring severe mental and substance use disorders, Journal of Substance Abuse Treatment, 34: 123-138. 10 year course of remission, abstinence, and recovery in DD Xie, Drake, McHugo, Xiec, Mohandas (2010). Journal of Substance Abuse Treatment

Integrated Dual Disorder Treatment (IDDT): What is it? Integrate Dual Disorder Treatment (The Dartmouth Model) – Dartmouth Psychiatric Research Institute Robert Drake, MD and colleagues, 2000 Integrate treatment of substance use disorder and mental illness together for more effective mgmt.: Same team(s) Same location Same time frame

IDDT Principles

What is IDDT? An evidence-based practice for those with co-occurring severe mental illness and substance use disorders. Research shows IDDT Reduces: relapse, arrest, incarceration, duplication of services, service costs and utilization.

Continuum of Symptom Severity Quadrant I LOW Severity - MH Symptoms LOW Severity - SUD Symptoms Quadrant II HIGH Severity – MH Symptoms LOW Severity – SUD Symptoms Quadrant III LOW Severity - MH symptoms HIGH Severity – SUD symptoms Quadrant IV HIGH Severity – SUD Symptoms **IDDT Services focus on a client in this quadrant** Quadrants

IDDT improves abstinence outcomes This slice shows data from the New Hampshire psychiatric institute treatment studies (2004-06) of persons with dual disorders. You can see by looking at the red line that people who received integrated treatment were much more likely to recover from the substance use disorder than people who received parallel treatment, which is shown by the yellow line. After receiving treatment for 4 years, only about 20% of those in parallel treatment had recovered, whereas almost 60% of those in integrated treatment had recovered.

Columbus VAMC

Columbus VAMC

What is IDDT? Stage-wise approach to treatment, individualized to address the readiness of each client.

Stage-Wise Treatment Pre-contemplation - ENGAGEMENT Outreach, practical help, crisis intervention, develop alliance, assessment Contemplation & Preparation - PERSUASION Education, set goals, build awareness of problem, family support, peer support Action – ACTIVE TREATMENT Substance abuse counseling, medication treatments, social skills training, living skills training, leisure skills training, community reinforcement, self-help groups Maintenance – RELAPSE PREVENTION Continue skills building in active treatment, expand recovery to other areas of life

IDDT @ Cleveland VAMC Two Programs Involved Currently: Psychosocial Rehabilitation and Recovery Center (PRRC) Recovery Resource Center’s (PRRC) aim is to provide evidence-based skills training that promotes recovery, education, and community integration for veterans with a primary diagnosis of serious mental illness (SMI) . Located at 7000 Euclid Ave. Mental Health Intensive Case Management (MHICM) is a Parma-based team. Aim is to provide intensive, community-based case management to assist with transition from higher levels of care, decrease recidivism and improve community functioning.

IDDT Implementation & Practice at VA Readiness assessment Training, Fidelity and Consultation Developing a set criteria Centralized referral system (needed in a system of care) Intake and assessment Staging veterans to ensure interventions match client’s stage of treatment or readiness to change. Documentation (assessments, notes, plans) reflect stage-wise approach.

Implementation Lessons Learned Best practices and EBPs are preferred because they have strong conceptual support – and - empirical support that they work Training alone is insufficient to change practice behavior. On-going supervision is essential. Change occurs in stages and takes time

Implementation Lessons Learned Intellectual buy-in does not necessarily equal changed practice….new behavior is required It is common to underestimate the complexity of implementation and change Using instruments that help you compare your progress across specific structural and clinical domains helps focus an intentional process Ongoing attention to process/fidelity/outcomes is critical

Challenges and Lessons Learned at VA Began with two separate teams, but quickly realized this left us not realizing program strengths. Stage-wise groups could be provided at the centrally located PRRC and run by both MHICM and PRRC staff & peers. Goal is for individuals to have comprehensive set of services which includes: Assertive Outreach by the MHICM team Psychosocial rehab services (coaching, goal-setting, skills groups, community-based skills) at the PRRC.

Challenges and Lessons Learned at VA What is the current demand? Coordinating efforts with other levels of care and programs that serve similar clients (PRRTP, VARC, Day Hospital, MHACC, WCT-6, CHC Outreach programs) and informing them services available in MHICM & PRRC Continuing to insert IDDT principles into all services to install a consistent approach across continuum of care

Challenges and Lessons Learned at VA Clearly defining how each team functions within this model to provide the most efficient/integrated service: System of coordination for shared clients Using strengths of each program in coordination efforts (e.g., assertive outreach in MHICM and wide array of groups in PRRC) Staff turnover & Outcomes Assessment

Guided Discussion Questions What barriers have you experienced treating or helping individuals with complex Behavioral Health needs? What successes have you had? What are some ways we can partner to address the opiate crisis and caring for our most complex clients?

Contact Information Primary Contacts: Dr. Michael Biscaro, PRRC Program Coordinator, (216) 391-0264 x2033, (216) 314-6955, Michael.Biscaro@va.gov Patrick Boyle, Ph.D., LISW-S, LICIC-CD, CEBP at CWRU, (216) 368-0808, patrick.boyle@case.edu David Ditullio, LISW-S, MHICM Team Leader, (216) 739-7000 x2324, (216) 855-5809, David.Ditullio@va.gov Alisa Sprague, MHICM/CRC/CAP Program Manager, (330) 761-7054 x2028 or Alisa.Sprague@va.gov