mental health and substance use - ohrdp · mental health and substance use: concurrent disorders...

Mental Health and Substance Use: Concurrent Disorders Capacity and

Harm Reduction

2012 Ontario Harm Reduction Conference

Allison Potts, MSW, RSW

Concurrent Disorders System Integration Lead

Mental Health and Pinewood Centre Program

Lakeridge Health

[email protected]

Welcome

Who is here?

Why does this

matter?

Who should it

matter to?

Allison Potts, January 2012

Session Content

A Question you came in this room with…

Quick review of what Concurrent Disorders means and the important fit with Harm Reduction

Concurrent Disorders Capacity Building, Harm Reduction and the process of change


What are CD? Concurrent Disorders refers to cases where the

individual has both a substance use concern and

another serious mental health or psychiatric

concern (same time or in sequence)

Other terms:

◦ Dual Diagnosis – popular in American literature, but in

Canada refers to a Mental Health disorder and a

developmental disorder – obvious limits are being

increasingly recongnized

◦ Co-Occurring Disorders – commonly accepted term

internationally for CD


What’s Your Number?


Access To Treatment

Research comparing treatment of patients with a depressive disorder and coexisting substance use issue found that they experience greater complexity of psychosocial needs and clinical presentation than those diagnosed with depression alone and they have fewer admissions and shorter lengths of stay.

Brems et al 2006, Journal Of Dual Diagnosis (Research conducted in Alaska Psychiatric Institute).

Access to medical care, and clarity regarding diagnoses, HIV status and other health concerns are also impacted by this

The difficulty for research to be done on complex samples (aka people with more than one presenting issue) has impacted the availability of data supporting evidence based practices for individuals with CD


Common Factors of Mental Illness

and Substance Abuse

Brain impact

Impaired insight

Chronic, relapsing conditions

Impacts family and significant others

Stigmatized

Shame and guilt

Can be treated


Factors Influencing Concurrent

Disorders

Factors influencing the development of mental

health and substance use issues are similar:

◦ Genetic, developmental and environmental factors

interact and influence outcomes

◦ They can mask, mimic, exacerbate, trigger, complicate

and possibly be independent of each other


So How Can They Interact?

MASK: Symptoms of mental illness may

be hidden by drug and alcohol use.

Example: Someone with a history of

trauma may be using oxycontin for relief.

The full understanding of PTSD may not

be apparent until he/she stops using

substances for a significant period of time.



MIMIC: Substance use can look like

symptoms of a psychiatric disorder.

Example: A person with no history of

psychiatric symptoms can develop tactile

hallucinations after heavy

methamphetamine use.



EXACERBATE: Symptoms of mental illness may get worse when an individual uses alcohol and drugs.

Example: Someone may experience increases in auditory hallucinations during and after use of cannabis as they may react to the hallucinogenic properties of the substance.



TRIGGER: Substance use can trigger the

emergence of some mental health disorders

if a youth is predisposed to mental illness.

Example: A youth whose mother has

bipolar disorder may have never

experienced symptoms of mania until the

youth uses Cocaine.



COMPLICATE: Substance use can

complicate psychiatric symptoms,

assessment and treatment.

Example: Treating any mental illness is

complicated by substance use – if there is

active cocaine use, how can positive

symptoms, such as paranoia be assessed?


Evidence Based Practices for CD

The most consistent finding across recent studies is that integrated treatment programs are highly effective

Ideally, integrated treatment means that the clinician weaves the treatment interventions into one coherent package

Several outpatient and residential studies also support the use of Stage-Wise treatments (based on the Transtheoretical Model of Change – Prochaska & DiClemente 1984), Engagement Techniques and Motivational Counselling Techniques

Drake, R., Mueser, K., Brunette, M., & McHugo, G. 2004


Concurrent Disorders are an Expectation, not an Exception

This expectation must be incorporated in a

welcoming manner into all clinical contact, to

promote access to care and accurate

identification of the population

Dr. K. Minkoff

A Four Quadrant Model of Concurrent Disorders

Quadrant 3

CD Capable services

delivered to individuals with

high severity of substance

use issues and low severity

of mental illness.

Consultation/Collaboration

Quadrant 4

Coordinated CD capable and

enhanced services are


high severity of both

substance use and mental

illness.

Integration

Quadrant 1

CD Capable services


low severity of both mental

illness and substance use.

Care is provided throughout the

health care system and all points

of entry should support recovery

and use of consultation.

Quadrant 2

CD Capable services delivered

to individuals with high

severity of mental illness and

low severity of substance use.

Consultation/Collaboration

Severity of

Substance Use

LOW Severity of Mental Illness HIGH

LOW

HIGH


A System of Silos

Historically, individuals with CD have encountered a treatment system that is disjointed and unwelcoming reflecting:

◦ Sequential Treatment: Patients frequently experienced a “ping pong” effect of moving between components of the system that are unconnected and uncoordinated

◦ Parallel Treatment: Simultaneous treatment occurring without consultation or collaboration resulting in high potential for conflicting treatment plans, over-servicing while under-providing

◦ No Treatment at all: Closed doors due to Stigma associated with substance use issues and mental illness and misperception regarding inter-relatedness of CD


Program/Structural Barriers Lack of programming

that encompasses both substance use and mental health concerns

Exclusion Criteria

Focus on abstinence

Waitlists, workloads

Geography

Lack of accessibility to programs

Lack of CD Capacity

Poor outreach

Sorry, wrong door! Allison Potts, January 2012

The Outcome of Silo Work?

Compounded feelings of stigma (living with a mental illness, substance use, criminal record, and…)

Unclear/Competing understanding or perspectives of the “primary problem”

Lack of coordination in service response and transitions

The burden of repeatedly sharing your story – and feeling the need to fragment it to meet system criteria


Rationale for System Design

(and change)

CD as an expectation in all settings, not an exception

Rule it out rather than Rule it in

Striving for a minimum standard of concurrent

disorder capability as a mechanism for reducing the

poor outcomes and high costs of concurrent disorders

Includes the understanding that each program within

the system has a different “job”, but better utilizing

these programs and matching services to determine

most appropriate interventions


Counsellor Barriers to CD Capable

Work…

Lack of confidence regarding discussing substance use and/or mental illness (psychotic symptoms and risk of suicide in particular)

How do I ask? And then what do I do?

Uncertainty about what to do with the responses

Personal bias/experiences

Sense that there is system resistance to change

Access to screening/assessment tools and referral/consultation supports

Lack of knowledge of terminology

Interest and agency mandate (real or perceived)


Client Barriers to Involvement

Concern of being judged – under-report Lack of hope Lack of awareness of treatment options Individual may deny or under-recognize the

existence of a problem in an attempt to normalize their situation

Previous negative experiences in treatment system

Peer groups reinforce normalcy of use or problem


What Could We Be Doing Better?

The role for programs that offer HR

distribution and support…


What is CD Capacity Building?

Enhancing and Developing Skills, Influencing Change in Organizational Structures, and a Commitment to Overall Health Improvement

Hawe et. al. 2000

Addressing the Gap between mental health and addictions treatment

Building on the strengths of current services and programs

Broadening the Base of treatment and increasing existing capacity


Components of CD Capacity Building

System based – structures, procedures, policies and practices (important to have top level “buy in”)

Resource level – redirection of $

Clinician & Team based – support, information, resources and commitment

Partnerships & Collaboration

Development of Leadership


System Based – Structures, Procedures,

Policies And Practices

◦ Management adopting CD best practices(and

in our case CCISC Model)

◦ Recognize the value of CD Capacity building

from a team level

◦ Support consistent policy and procedures

regarding CD (eg.Welcoming, Collaborative

treatment models, opportunities for inclusion)


Resource Level – Redirection Of $

◦ In many cases, this work has been based on a

“no new money” premise to begin with –

spending better not less or more…yet

◦ Community partnerships – sharing resources

with other agencies

◦ Collaborative proposals for funding


Partnerships & Collaboration

CD Capacity is built by clinicians from MH and SU services developing pilot projects, cross-training, collaborative case conferences, co-facilitating groups

It is also built by learning from and with the individuals accessing services, by hearing the experiences and needs of consumers

This is an opportunity re: Harm Reduction


Harm Reduction

Non-judgmental, non-coercive provision of

services

Low-threshold program models

Getting resources to people who use drugs

A continuum approach to harm reduction

includes abstinence

HR programs have a vital role in support of

CD Capacity Building in their communities


Harm Reduction and Abstinence:

What Community Partners Need

to Know Harm reduction and abstinence are highly

congruent goals.

Harm reduction expands the therapeutic conversation, allowing providers to intervene with active users who may not or are not yet contemplating abstinence.

Harm reduction strategies can be used at

any phase in the change process.

Midwest Harm Reduction Institute


Development of Leadership - Opportunities

to Build Capacity

Regional Leaders – sitting at broad system tables

to champion CD System Integration

Concept of “Site Champions” and a mechanism for supporting development that can be transferred through leaders

Clinical leadership – fostered through supervision and team support

System Advocacy


What can be gained from increased CD

Capacity?

Reduced Stigma

Improved treatment outcomes

◦ Improved Screening & Identification

◦ Better clinical coordination

Providing service to the Whole Person

Enhanced professional development for staff

Increased job satisfaction

HARM REDUCTION Allison Potts, January 2012

Going Forward

Linkages

Partnerships

Stepping out of silos

Cross-training

Assessing strengths and areas of growth


Websites of Interest

Pinewood Centre: www.pinewoodcentre.org

Minkoff & Cline – ZiaPartners http://www.ziapartners.com/

www.kenminkoff.com

Centre for Addiction and Mental Health (CAMH): www.camh.net

Mood Disorders Association of Ontario (MDAO):

www.mooddisorders.on.ca

Canadian Mental Health Association: www.cmha.ca

ConnexOntario: www.connexontario.ca

Rights and Responsibilities: Mental Health and the Law

www.health.gov.on.ca/english/public/pub/mental/rights.html


http://www.pinewoodcentre.org/

http://www.ziapartners.com/

http://www.ziapartners.com/

http://www.kenminkoff.com/


http://www.camh.net/

http://www.mooddisorders.on.ca/

http://www.cmha.ca/

http://www.connexontario.ca/

http://www.health.gov.on.ca/english/public/pub/mental/rights.html


References

Bouis, Stephanie, et.al. An Integrated, Multidimensional Treatment Model for Individuals Living with HIV, Mental Illness, and Substance Abuse, Health and Social Work, 32:4, November 2007: 268 – 278.

Boyle, P. and Kroon, H. Integrated Dual Disorder Treatment International Journal of Mental Health, 35, 2, Summer 2006: 70-88.

Brems, C. et al. Comparing Depressed Psychiatric Inpatients with and Without Coexisting Substance Use Disorders Journal of Dual Diagnosis, 2 (4), 2006, 71-78.

Drake, R., Meuser, K., Brunette M.,McHugo, G. A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring Substance Use Disorders Psychiatric Rehabilitation Journal, 27-4, Spring 2004, 360-374.

Minkoff, K and Cline, C. Changing the World: The Design and Implementation of Comprehensive Continuous Integrated Systems of Care for Individuals with Co-occurring Disorders. Psychiatric Clinics of North America, 27 (4):727-43, 2004

Sealy, John R. Dual and Triple Diagnoses: Addictions, Mental Illness, and HIV Infection Guidelines for Outpatient Therapists Sexual Addiction & Compulsivity, 6:195-219, 1999.

Whetten, K. et.al. Improving Health Outcomes Among Individuals with HIV, Mental Illness, and Substance Use Disorders in the Southeast AIDS Care, 2006; 18 (Supplement 1): S18-S26.

Panel on Antiretroviral Guidelines for Adult and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 29, 2008; 1-128. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed March 25, 2008


http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed March 25




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