1. “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)

2. 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

3. 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.

4. 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) Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007.

5. 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

6. 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

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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:
10 year course of remission, abstinence, and recovery in DD
Xie, Drake, McHugo, Xiec, Mohandas (2010). Journal of Substance Abuse Treatment

13. 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

14. IDDT Principles

15. 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.

16. 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

17. IDDT improves abstinence outcomes
This slice shows data from the New Hampshire psychiatric institute treatment studies ( ) 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.

18. Columbus VAMC

19. Columbus VAMC

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

21. 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

22. 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.

23. 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.

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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?

30. Contact Information
Primary Contacts:
Dr. Michael Biscaro, PRRC Program Coordinator, (216) x2033, (216) ,
Patrick Boyle, Ph.D., LISW-S, LICIC-CD, CEBP at CWRU, (216) ,
David Ditullio, LISW-S, MHICM Team Leader, (216) x2324, (216) ,
Alisa Sprague, MHICM/CRC/CAP Program Manager, (330) x2028 or