1. Vivian B. Brown, Ph.D. PROTOTYPES Ken Bachrach, Ph.D. Tarzana Treatment Center Lisa Melchior, Ph.D. The Measurement Group Introducing the COJAC Screener: A Short Screening Instrument for COD and Trauma

2. What is COJAC? In the summer of 2005, the State Co-Occurring Disorders Workgroup/COD Policy Academy members, along with representatives from the County Alcohol and Drug Program Administrators Association of California (CADPAAC) and the California Mental Health Directors Association (CMHDA), formed the Co-Occurring Joint Action Council (COJAC) to develop and implement the State’s COD Action Plan

3. The Screening Committee of COJAC One of the major objectives of the COJAC State Action Plan was to identify screening protocols designed to meet the needs of a variety of populations served by both AOD and Mental Health Systems, including adolescents, women with children, adults, and transition age youth with trauma The Screening Committee was established; chair of the committee is Dr. Vivian Brown

4. The Screening Committee of COJAC The Committee was charged with identifying the best screening tool(s) for COD The Screening Committee identified all instruments being utilized across the country; we found that the most widely used instruments were those designed either for identification of substance abuse or identification of mental illness

5. The Screening Committee of COJAC We, therefore, decided to design a California screening tool that not only would identify COD, but would be short enough to not burden clients nor staff, and simple enough to be utilized in a wide range of community service sites (including emergency rooms)

6. What is the COJAC Screener? The Co-Occurring Disorders Screening Instrument is composed of 9 questions: –3 questions on mental health –3 questions on alcohol and drug use –3 questions on trauma These questions were adapted from the Collaborative Care Project, Canada, and the Co- Morbidity Screen from the Boston Consortium

8. Pilot Testing Pilot testing of the screener was implemented by PROTOTYPES and Tarzana Treatment Center in May 2007; both agencies have Community Assessment Service Centers (CASCs), AOD programs, and mental health programs The Screening Committee set the cut point for pilot testing low – at 1 point, in order to test the COJAC Screener with the GAIN Short Screener (SS) and the Addiction Severity Index (ASI)

9. Pilot Testing Tarzana did not use the GAIN – only the ASI; Tarzana piloted the COJAC Screener on 1,386 clients, including 51% AOD clients, 12% CASC, 31% primary care, 5% ER, and 2% high school students PROTOTYPES piloted on 365 CASC clients: over 10% had COJAC Screener and GAIN SS; 90% had COJAC and ASI

10. Select Data from PROTOTYPES Type of COD with Positive Screen FrequencyValid PercentCumulative Percent None4211.5 MH Only215.817.3 AOD Only9526.043.3 Trauma Only61.644.9 MH & AOD5515.160.0 MH & Trauma205.565.5 AOD & Trauma3710.175.6 MH & AOD & Trauma8924.4100.0 Total365100

11. Select Data from Tarzana Yes Responses to Mental Health Questions Primary CareCASCSchoolAODER (Medical)OV CASC 15%24%42%47%63%70% Yes Responses to Alcohol and Drug Use Questions Primary CareCASCSchoolAODER (Medical)OV CASC 14%45%46%72%80%92% Yes Responses to Trauma/Domestic Violence Questions Primary CareCASCSchoolAODER (Medical)OV CASC 10%13%25%30%

12. Pilot Testing Results What the Screening Committee was attempting to answer with this first pilot was: 1.Will this short screener pick up potential COD and will it be correlated with longer screening instruments? 2.Will this screener be easy to administer; not burden client nor staff? 3.Are the results good enough to begin implementation?

13. Question 1: Picking up COD PROTOTYPES Sample More than half of those screened (55.1%), screened positive in at least 2 of the 3 domains 30.7% screened positive in 2 domains 24.4% screened positive in all 3 domains Only 11.5% did not identify problems in any of the 3 domains

14. Question 1: Picking up COD Tarzana Sample We get an interesting picture of responses across 6 groups; across groups, 76% responded with at least one “yes” response –Primary Care: 4-18% responded positive to all questions; 23% have been worried about MH –ER: 52% worried about thinking, etc. (MH) –Olive View CASC: 79% positive for MH, 90-95% positive for AOD; 53% positive for partner DV –High School: 40% worried about MH; 31% harmed self or thought of harming self; 42% AOD, 42% partner abuse; 35% physical abuse

15. Question 1: Correlated with Other Screeners PROTOTYPES Sample The 3 MH screening questions appear to have a strong relationship with the GAIN MH measure (both internal and external) and the ASI psychiatric problem severity The 3 AOD questions appear to have a strong relationship with the GAIN substance disorder measure, but minimal to the ASI AOD severity measures The 3 Trauma questions appear strongly related to the GAIN crime/violence measure (more than the MH measure) and also appear to relate strongly with the ASI psychiatric problem severity

16. Question 1: Correlated with Other Screeners Tarzana Sample Tarzana data looked at item by item Responses to MH COJAC and ASI were in the same direction and chi-square tests were strong For AOD, COJAC and ASI, drugs were in the same direction, but alcohol questions were not There was only one ASI question to compare COJAC and ASI trauma; responses were in same direction, but not significant

17. Question 2: Comfort/Not Burdensome In discussions with PROTOTYPES staff and Tarzana staff, it appeared that neither staff nor clients were burdened by the COJAC Screener

18. Question 3: Results Good Enough to Go to Next Steps From both pilot sites, the answer appears to be yes

19. Limitations of Pilot Testing While we set the cut point low at 1 “yes,” we do not have data analyzed for negatives; i.e., those people who had zero on COJAC and GAIN data – would GAIN have picked up other problems? We did not analyze by gender and this could explain some issues of the trauma questions

20. Next Steps A meeting was held with all CASC directors to discuss the positive results of the pilot testing and possible implementation by all CASCs Los Angeles and other Counties have decided to begin implementation of the COJAC Screener, with the cut point raised to a minimum of two “yes” responses – one in MH and one in AOD or one in either MH and AOD and one in trauma State ADP is implementing an expanded pilot test of the Screener

21. The COJAC Screening Committee Vivian B. Brown, Prototypes – Chair Carmen Delgado, ADP Terry Robinson, ADPI Tom Metcalf Karen Streich, LA County DMH Lisa Melchior, The Measurement Group Sandy Mills, LA County DMH John Sheehe, LA County DMH

22. The COJAC Screener Albert Senella, Ken Bachrach, Ph.D. & Clarita Lantican, Ph.D. Tarzana Treatment Centers Sixth Annual Conference on Co-Occurring Disorders Long Beach, CA February 7, 2008

23. Survey Timeframe & Sites Data collected the entire month of May 2007 Data collected the entire month of May 2007 Tarzana Treatment Center sites Tarzana Treatment Center sites Inpatient detox Inpatient detox 3 adult residential programs in Tarzana, Long Beach and Lancaster 3 adult residential programs in Tarzana, Long Beach and Lancaster 1 youth residential program in Lancaster 1 youth residential program in Lancaster 2 outpatient programs in Tarzana and Lancaster 2 outpatient programs in Tarzana and Lancaster 2 substance abuse assessment centers in Tarzana and Lancaster 2 substance abuse assessment centers in Tarzana and Lancaster Northridge Hospital Medical Center ER Northridge Hospital Medical Center ER Olive View Hospital ER Olive View Hospital ER

24. Survey Participant Groups AOD – TTC patients admitted to Detox, Residential and Outpatient programs at all sites. AOD – TTC patients admitted to Detox, Residential and Outpatient programs at all sites. Primary Care – TTC Family Clinic patients in Tarzana and Lancaster. Primary Care – TTC Family Clinic patients in Tarzana and Lancaster. CASC – Clients referred to Community Assessment & Service Centers in Tarzana and Lancaster for substance abuse assessment. CASC – Clients referred to Community Assessment & Service Centers in Tarzana and Lancaster for substance abuse assessment. ER (Medical) – Emergency Room patients at Northridge Hospital and Olive View Medical Center. ER (Medical) – Emergency Room patients at Northridge Hospital and Olive View Medical Center. Olive View CASC – Clients referred to CASC for psychiatric assessment. Olive View CASC – Clients referred to CASC for psychiatric assessment. School – High School students in Lancaster participating in a substance abuse and HIV prevention project. School – High School students in Lancaster participating in a substance abuse and HIV prevention project.

25. Survey Participants A total of 1,386 patients/clients participated in the survey: A total of 1,386 patients/clients participated in the survey: 51% AOD patients 51% AOD patients 31% primary care clinic patients 31% primary care clinic patients 12% Community Assessment & Service Center (CASC) clients 12% Community Assessment & Service Center (CASC) clients 5% ER patients for medical & psychiatric care 5% ER patients for medical & psychiatric care 2% high school students 2% high school students

26. *Responded "yes" to one or more of the 3 COJAC questions Positive Responses * for MH, AOD and Trauma / Domestic Violence Based on COJAC Screen MHAOD Trauma / Violence PercentPercentPercent Primary Care 151410 CASC244513 School424625 AOD477230 ER(Medical)638030 OV-CASC709230

27. Comparison of AOD patient responses to COJAC and ASI for similar items Mental Heath COJAC (n =697) ASI (n =201) Have you ever harmed yourself or thought about harming yourself? (COJAC) 75% Serious thoughts of suicide – lifetime (ASI) 80% AOD Have you ever had any problem related to your use of alcohol or other drugs? (COJAC) 78% Troubled or bothered by drug problems in the past 30 days (ASI) 77%

28. Findings from Pilot Test The comparison between COJAC and ASI of MH and SA questions are statistically significant. Overall, the responses are in the same direction. The comparison between COJAC and ASI of MH and SA questions are statistically significant. Overall, the responses are in the same direction. The comparison between COJAC and ASI questions for trauma and domestic violence are not statistically significant. This can be explained by the fact that the ASI does not have a question that is a good match for COJAC questions. The comparison between COJAC and ASI questions for trauma and domestic violence are not statistically significant. This can be explained by the fact that the ASI does not have a question that is a good match for COJAC questions.

29. Conclusions The findings of the survey provide valuable insights on the history of TTC patients/clients concerning mental health, AOD and trauma/domestic violence issues. The findings of the survey provide valuable insights on the history of TTC patients/clients concerning mental health, AOD and trauma/domestic violence issues. The findings provide TTC the capability to identify the needs of patients/clients as part of substance abuse treatment. The findings provide TTC the capability to identify the needs of patients/clients as part of substance abuse treatment. The findings provide insights to prioritize the patients/clients in addressing their needs. The findings provide insights to prioritize the patients/clients in addressing their needs. More importantly, the findings show the validity of the COJAC tool as a screening tool. More importantly, the findings show the validity of the COJAC tool as a screening tool.

30. COJAC Co-Occurring Disorders Screening Instrument: Pilot Test Lisa A. Melchior, Ph.D. The Measurement Group Culver City, California In collaboration with Vivian B. Brown, Ph.D. and G. J. Huba, Ph.D. with additional contributions from Aaron Griffith, MA and Eva Sofia Mendoza. Pilot study data collection protocols were designed by the COJAC COD Screener Subcommittee.

31. About these Pilot Test Data PROTOTYPES collected pilot test data for the COJAC Co-Occurring Disorders Screening Instrument April – May 2007 Data were collected from 365 individuals at the PROTOTYPES SPA 3 CASC locations in El Monte, Pomona, and Pasadena n = 323  n = 268 with data from the COD screening instrument, Addiction Severity Index (ASI) composite scores, and ASI severity ratings  n = 34 with data from the COD screening instrument and the GAIN Short Screener (GAIN SS)

32. Preliminary Validity Evidence The COD screening items and composites are moderately correlated with ASI and GAIN measures of comparable constructs

34. Mental Health Screening The three mental health screening items on the COD screening instrument appear to have a strong relationship with ASI measures of psychiatric problem severity and GAIN mental health measures of internalizing and externalizing disorders These appear to work well as screening items for mental health issues

35. AOD Screening The three alcohol and drug use items on the COD screening instrument appear to relate minimally to ASI alcohol/drug problem severity measures There are stronger relationships between the alcohol and drug use COD screening items and the GAIN SS substance disorders measure

36. Trauma/DV Screening Similar to the mental health items, the three trauma/domestic violence items on the COD screening instrument also appear to relate strongly to ASI measures of psychiatric problem severity However, they differentiate with respect to the GAIN SS  The COD trauma screening items have stronger relationships with the GAIN SS Crime/Violence measure than with the mental health measures (for internalizing and externalizing disorders)  This is an important distinction that is consistent with constructs of trauma/domestic violence

37. Screening Composite Scores Composite scores were formed for each of the content areas in the COJAC COD screener  Count of number of items answered “yes” within each domain Mental Health (0-3) Alcohol/Drug Use (0-3) Trauma/Domestic Violence (0-3)  Plus total score across all nine items (0-9)

38. COD Screener Summary Scores and ASI Composite Scores Mental Health Items Alcohol & Drug Use Items Trauma/DV Items Total Score Medical.23**.00.14*.18** Employment.20**.09.18**.22** Alcohol.15*.14*-.04.12 Drug.02.16**.03.09 Legal.05.01.10.08 Family-Social.16*.03.17** Psychiatric.56**.11.33**.47** n = 268

39. COD Screener Summary Scores and ASI Severity Ratings Mental Health Items Alcohol & Drug Use Items Trauma/DV Items Total Score Medical.18**-.03.08.11 Employment-.08-.18**-.01-.12 Alcohol.08-.04-.08-.02 Drug.05-.08.07.02 Legal.02-.13*.12*.01 Family-Social.10-.13*.11.03 Psychiatric.56**.03.37**.46** n = 268

40. COD Screener Summary Scores and GAIN Short Screener Mental Health Items Alcohol & Drug Use Items Trauma/DV Items Total Score Internalizing Disorders.54**-.03.22.34 Externalizing Disorders.30-.09.09.14 Substance Disorders.04.60**.22.42* Crime-Violence.47**.48**.45**.66** Total Disorders.47**.39*.36*.57** n = 34

41. Mental Health Composite Overall, the Mental Health COD screening composite works well, correlating strongly with ASI and GAIN SS measures of mental health problems

42. AOD Use Composite The Alcohol/Drug Use COD screening composite relates well to the GAIN SS measure of substance disorder severity but not with the ASI alcohol and drug problems measures

43. Trauma/DV Composite As was the case for the individual trauma/domestic violence screening items, the Trauma/Domestic Violence COD screening composite related moderately to the ASI mental health measures and strongly with the GAIN SS crime/violence measure

44. Total COD Composite The Total COD screening composite correlated with ASI measures of psychiatric problems and GAIN SS measures of mental health, substance disorders, crime/violence, and total disorders It appears this measure shows promise for screening for co-occurring disorders

45. Pilot Study Limitation Because the instructions specifically indicated the longer screening measures (i.e., ASI, GAIN SS) were only to be administered if one or more answer to the nine COD screening items was endorsed, there is a restricted range of responses in the data available to “predict” scores on the longer (more established) criterion measures By design, it was not possible to examine whether negative screening data (i.e., cases where all nine items are answered “no”) predicts the absence of problems as measured by the ASI and/or GAIN SS These data do illustrate the degree to which persons screened as having a possible substance abuse, mental health, and/or trauma issue are likely to have treatment needs as measured by the ASI and GAIN SS measures That is, among persons already identified as having screened “positive” for one or more of these issues, endorsement of COD screening items and composites is related to the severity of substance abuse and mental health problems