Enhancing Co-Occurring Disorder Services in Addiction Treatment: Preliminary Findings of the Texas Co-Occurring State Incentive Grant Dartmouth Psychiatric Research Center Seminar May 2007

Texas COSIG Project The goal of the COSIG project is to improve the delivery of state-funded services for clients in Texas with co-occurring psychiatric and substance use disorders (COPSD). The goal of the COSIG project is to improve the delivery of state-funded services for clients in Texas with co-occurring psychiatric and substance use disorders (COPSD). The project consists of two components designed to promote system change and to enhance specialized clinical skills of providers treating COPSD. The project consists of two components designed to promote system change and to enhance specialized clinical skills of providers treating COPSD.

COSIG Project Component #1 Focused education at the clinician level regarding treatment issues relevant to COPSD and training on the use of diagnostic and assessment instruments to enhance identification of psychiatric comorbidity and monitor progress of clients. Focused education at the clinician level regarding treatment issues relevant to COPSD and training on the use of diagnostic and assessment instruments to enhance identification of psychiatric comorbidity and monitor progress of clients.

COPSD Curriculum Modules Module 1: Substance Use and Mental Health Disorders Module 2: Depression and Substance Use Disorders Module 3: Substance Use and Bipolar Disorders Module 4: Anxiety and Substance Use Module 5: Schizophrenia, Schizoaffective, and Substance Use Disorders Use Disorders Module 6: Substance Use – Motives and Consequences Module 7: Principles of Treatment Module 8: Relapse Prevention

Diagnostic and Assessment Measures  Mini International Neuropsychiatric Interview (MINI)  Brief Symptom Inventory (BSI)  Brief Derogatis Psychiatric Rating Scale (BDPRS)  Substance Abuse Treatment Scale (SATS)  Ancillary Service Assessment  Client Evaluation of Self in Treatment (CEST)

Counselor Comments on Use of Diagnostic and Assessment Measures  Repeated administration of the MINI has increased understanding of disorders and enhanced ability to recognize potential symptoms  Using results of measures has assisted in “bridging a gap” by facilitating interactions with mental health providers  Administration can enhance client awareness of COD issues – many have never been asked these questions before  Results highlight issues to be addressed in sessions with clients and provide a means to monitor progress

COSIG Project Component #2 A voucher system that provides additional funding for procurement of ancillary services in an effort to address the multifaceted needs of COPSD clients and to support the treatment and recovery process ($1,800 per client). A voucher system that provides additional funding for procurement of ancillary services in an effort to address the multifaceted needs of COPSD clients and to support the treatment and recovery process ($1,800 per client).

Voucher Service Categories  Child Care  Housing Support  Transportation  Food Assistance  Education Support  Employment Assistance  Clothing  Medical Care  Prescriptions  Peer Mentoring

Administration of Evaluation Measures

COSIG Treatment Providers

Program Summary Reports

Psychiatric Diagnostic Impressions Program X and COSIG Statewide (Data through March 2007)

Substance Use Disorders Program X and COSIG Statewide (Data through March 2007)

BSI Scores in the Clinically Significant Range Program X and COSIG Statewide (Data through March 2007)

BDPRS Ratings in the Marked to Extreme Range Program X and COSIG Statewide (Data through March 2007)

BSI and BDPRS Scores in the Clinically Significant Range Program X (N = 115) (Data through March 2007)

BDPRS and BSI Scores in the Clinically Significant Range COSIG Statewide (N = 756) (Data through March 2007)

SATS Ratings at Admission to COSIG Program X and COSIG Statewide (Data through March 2007)

BSI Scale Averages at Admission and One Month in COSIG Program X (N = 47) (Data through March 2007)

BDPRS Averages at Admission and One Month in COSIG Program X (N = 47) (Data through March 2007)

BSI Scores in the Clinically Significant Range at Admission and One Month in COSIG Program X (N = 47) (Data through March 2007)

BDPRS Ratings in the Marked to Extreme Range at Admission and One Month in COSIG Program X (N = 47) (Data through March 2007)

SATS Ratings at Admission and One Month in COSIG Program X (N = 47) (Data through March 2007)

Voucher Services Needed and Received at One Month in COSIG (Client Report) Program X (N = 47) (Data through March 2007)

Programs Value Regular Feedback Provider reported uses of data reports:  Internal monitoring of COSIG program implementation  Greater understanding of COD client characteristics and individual needs to guide programming  Board of Directors and Executive Management Team presentations  Presentations to other community service providers to enhance networking (i.e., probation department, homeless alliances, planning and advisory committees)  Data for grant and other funding applications

Preliminary Outcomes Client and Service Characteristics Associated with Treatment Completion

COSIG Client Outcomes  Data were obtained for 424 COSIG clients who entered and were discharged from substance abuse treatment during the period of February 2005 through October 2006  76% of the sample completed treatment  Treatment completers (n=323) and non- completers (n=101) were compared on client and service characteristics

Client Demographics  Treatment completers were more likely to be male (51% vs. 34%) and homeless (24% vs. 14%)  The groups did not differ in race/ethnicity, education, age, marital status, employment, or past year substance- related arrests

MINI Diagnostic Impressions

Psychiatric Symptom Severity  No differences were found in client- reported symptom severity on the Brief Symptom Inventory scales  Clinicians rated non-completers as having more severe symptoms on the interpersonal sensitivity, depression, and hostility scales on the Brief Derogatis Psychiatric Rating Scale

Primary Substance of Abuse

Substance Use Patterns  Completers reported a greater primary substance use during the month prior to admission (15 vs.12 days)  A greater percentage of non-completers reported polysubstance use (56% vs. 42%)  No differences were found in total years of primary substance use or history of IV drug use

Substance Abuse Treatment History

Discharge Characteristics  Completers had higher past month abstinence rates (88% vs. 61%)  Completers had higher past month AA attendance (95% vs. 78%)  No group differences were found in length of stay in treatment (approximately 100 days)

Voucher Service Utilization

Recovery and Social Support Service Combinations

Conclusions  Higher treatment completion for males indicates that women with COD may need specialized interventions in substance abuse treatment  A study analyzing gender differences using a subset of these data revealed that women demonstrated higher awareness of psychiatric issues relative to substance abuse problems, suggesting that substance abuse treatment inventions may need greater focus on the interaction of the two disorders* *(Mangrum, Spence, & Steinley-Bumgarner, 2006)

Conclusions  Lower completion rates for clients with bipolar and posttraumatic stress disorders suggest that these syndromes may be more difficult to treat in substance abuse treatment settings  Substance abuse counselors may need training on specific interventions targeting these two disorders

Conclusions  The 76% completion rate for the total sample is higher than previously calculated statewide averages, suggesting that the provision of recovery and social support services may enhance treatment outcomes  A study examining clients receiving COPSD services in Texas during FY 2004 revealed a 57% completion rate*  Other analyses of general substance abuse treatment clients in Texas have indicated completion rates ranging from % *(Mangrum & Spence, 2005)

Conclusions  Peer mentoring had the strongest association with treatment completion  Social support services, particularly in the absence of peer mentoring, were associated with non-completion  Similar trends have been found in the Texas ATR voucher service data, indicating that direct recovery support services are associated with greater completion rates, whereas the provision of social support services only is more highly associated with non-completion

DDCAT Assessments Preliminary Results

Overall DDCAT Scores DDE: 5 DDC: 3 AOS: 1

Dual Diagnosis Capability Classifications Criterion Method ScoringScale Method Scoring

DDCAT Scale Scores by Program DDE: 5 DDC: 3 AOS: 1

Average DDCAT Scale Scores Statewide DDE: 5 DDC: 3 AOS: 1