Integrated Dual Disorder
Treatment (IDDT)
Evidence Based Practice
Kick Off Presentation
Evidence-Based Practices
Copyright West Institute
What are dual disorders?

Mental illness and substance use disorder
occurring together in one person
Evidence-Based Practices
Copyright West Institute
Why focus on dual
disorders?



Substance use disorders are common in people
with severe mental illness
Mental illness is common in people with
substance use disorders
Dual disorders lead to worse outcomes and
higher costs than single disorders
Evidence-Based Practices
Copyright West Institute
How common are these
problems in Americans?

Mental illness
•
•
•
•
Depression 15%
Anxiety Disorders 13%
Bipolar 1%
Schizophrenia 1%

Substance use disorders
• Alcohol 20%


• Drugs 9%


Evidence-Based Practices
Men 30%
Women 10%
Men 11%
Women 7%
Copyright West Institute
Substance abuse is common in
people with mental illness


Over 50% of people with schizophrenia,
bipolar disorder and other severe mood
disorders have a substance use disorder at
some time in their life
About one third of people with anxiety and
depressive disorders have a substance use
disorder at some time in their life
Evidence-Based Practices
Copyright West Institute
Prevalence of substance use
disorders in mental illness
60
50
40
% of
respondents
with substance 30
use disorder
20
10
0
Gen pop
Evidence-Based Practices
Schiz
Bipolar Maj dep
OCD
Panic
Copyright West Institute
% of respondents
Prevalence of Co-Occurring
Disorders-ECA Study
100
90
80
70
60
50
40
30
20
10
0
Schizophrenia
General Population
Alcohol Use
Disorder
Evidence-Based Practices
Regier et al., JAMA, 1990
Drug Use
Disorder
Alcohol or
Drug Use
Disorder
Copyright West Institute
Prevalence of mental illness in
alcohol disorder samples

70
60

50
40

30
20
10
0
Community
In community, 24.4%
have mental illness
In institutions, 55%
have mental illness
In substance abuse
treatment, 65% have
mental illness
SA
Treatme nt
Evidence-Based Practices
Copyright West Institute
Combination and levels of
illness
Mild to moderate
mental illn ess symptoms
Mild to moderate
substance use disorder
Severe
mental illn ess symptoms
Mild to moderate
substance use disorder
Mild to moderate
mental illn ess symptoms
Severe
substance use disorder
Severe
mental illn ess symptoms
Severe
substance use disorder
Evidence-Based Practices
Copyright West Institute
Types of Dual Disorders

Three categories
• Milder mood/anxiety disorder with substance use
disorder
• Personality disorder and substance use disorder
• Severe mental illness and substance use disorder
Evidence-Based Practices
Copyright West Institute
Integrated Dual Diagnosis Treatment
Implementation Materials

Materials focus on treatment for persons with
severe and persistent mental illness and
substance use disorder
•
•
•
•
Psychotic disorders
Bipolar disorders
Other severely disabling mental disorders
Any level of co-occurring substance use disorder
Evidence-Based Practices
Copyright West Institute
Course of dual disorders


Both substance use disorders and severe
mental illness are chronic, waxing and waning
Recovery from mental illness or substance
abuse occurs in stages over time
•
•
•
•
•
Precontemplation
Contemplation
Preparation
Action
Maintenance
 Prochaska, DiClemente, and Norcross 1992;
 Miller and Rollnick 1991
Evidence-Based Practices
Copyright West Institute
Course of dual disorders

People SMI and social substance use



Become abstinent or develop substance use disorder
Can’t tolerate social use
People with more severe substance use
disorders

Most get worse

Bartels et al, 1995
Evidence-Based Practices
Copyright West Institute
Attaining remission
occurs in stages
Grap
are
QuickTim
needed
hics deco
e™toand
smpresso
eeathis picture.
r
100
90
80
Recovered
70
Relapse Prevention
Percent
60
Late Active Treatment
50
Early Active Treatment
40
Late Persuasion
30
Early Persuasion
20
Engagement
10
Pre-engagement
0
0 mo.
Evidence-Based Practices
6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.
Assessment Point
Copyright West Institute
Dual disorders lead to worse
outcomes than single disorders







Relapse of mental illness
Treatment problems and hospitalization
Violence, victimization, and suicidal behavior
Homelessness and Incarceration
Medical problems, HIV & Hepatitis risk behaviors and
infection
Family problems
Increase service use and cost
Evidence-Based Practices
Copyright West Institute
Evidence-Based Practices
Copyright West Institute
Characteristics Associated with
Medication Noncompliance
in Six-Month Longitudinal Study
Characteristics
Odds Ratio
95% CI
Substance Abuse
8.1
2.5-26
0.13
0.01-1.2
0.53
O.25-1.1
(0=none, 1=current)
Observed Side
Effects
(0=none, 1=any SE)
Outpatient
Contacts
(0=none, 1=1-6, 3=>6)
Owen et al, Psychiatric Services 1996
Evidence-Based Practices
Copyright West Institute
Medical Complications of Co-Occurring Substance
Use: HIV and Hepatitis B and C
25%
20%
15%
10%
5%
0%
Seroprevalnce Rates in SMI
Sample
HIV (N=931)
HBV (N=751)
Persons with Substance Use
Disorders had
3 times higher chance of
having HIV
2 times higher chance of
having HBV
2. 5 times higher chance of
having HCV
HCV(N=751)
Evidence-Based
Practices
Rosenberg et
al., A Jl Public Health, 2001
Copyright West Institute
Monthly Income and Expenditures
for Substances Among 105 Patients with
schizophrenia




Monthly income
Disability income
Expenditures for illegal drugs
Expenditures for alcohol
$650
$645
$250
$10
• Median values
Evidence-Based Practices
Copyright West Institute
Costs of treatment for persons with dual
disorders compared to SMI only
Treated for Substance Not treated for
Use (N=1,493)
Substance Use
___________________ (N=4,394)____
No substance use
(N=10,509)
______________
$22,917
$13,930
$20,049
Dickey and Azeni, Am J Public Health, 1996
Evidence-Based Practices
Copyright West Institute
Recovery
•Dual disorders are treatable
•Many people attain stable remission of
substance use
disorders over time
•Recovery encompasses other areas of
adjustment
Health, work, housing, relationships
Mead et al, 2000
Evidence-Based Practices
Copyright West Institute
Traditional treatment

Treat each disorder separately
• May be parallel or sequential

Separate treatment is NOT effective
Evidence-Based Practices
Copyright West Institute
Evidence Based Practice

Definition of EBP
• Research evidence that practice is more effective
than usual treatment from multiple studies across
the country

Overview of national project
• Implementation kits for 6 evidence based practices
for public mental health
• Several states attempting to implement each EBP
• National study of implementation

Process, feasibility, outcomes
Evidence-Based Practices
Copyright West Institute
Integrated dual disorders
treatment: What is it?

Treatment of substance use disorder and
mental illness together
•
•
•
•
Same team
Same location
Same time
Other characteristics to be described later
Evidence-Based Practices
Copyright West Institute
Why integrated treatment
of dual disorders?


More effective than separate treatment
10 studies show integrated treatment is more
effective than traditional separate treatment
• (Drake et al, Schiz Bull 1998 and Drake et al, Psych Services
2001 for summaries).
Evidence-Based Practices
Copyright West Institute
IDDT improves abstinence
Evidence-Based Practices
Copyright West Institute
Fidelity to IDDT principles
improves abstinence
Evidence-Based Practices
McHugo et al, 1999
Copyright West Institute
Abstinence leads to improvements
in other outcomes Drake et al, 1998






Reduce institutionalization
Reduce symptoms, suicide
Reduce violence, victimization, legal problems
Better physical health
Improve function, work
Improve relationships and family
Evidence-Based Practices
Copyright West Institute
Stable remission improves
other aspects of life


Objective: Living situation, victimization
Subjective: overall satisfaction with life,
housing, family, health
Evidence-Based Practices
Copyright West Institute
NH Dual Diagnosis Study
(1989-1994 Drake et al, 1998)
Proportion of Days in Stable Community Housing
1.0
0.9
0.8
0.7
Beginning
6 months
12 months
All DD Patients (N = 203)
18 months
24 months
30 months
36 months
Patients in Recovery (N = 54)
1. Proportion of days in stable community housing (regular apartment or house, not in hospital, jail,
homeless setting or doubling with friends or family) increased for all dual diagnosis clients.
2. They increased more rapidly for persons in recovery (no substance abuse for at least 6 months).
Evidence-Based Practices
Copyright West Institute
NH Dual Diagnosis Study (19891994)
Percentage of Persons Hospitalized
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Beginning
6 months
12 months
All DD Patients (N = 203)
18 months
24 months
30 months
36 months
Patients in Recovery (N = 54)
1. Percentage of persons hospitalized during each six months declined
significantly for all clients.
2. It declined much more for those in recovery.
Copyright West Institute
Evidence-Based Practices
NH Dual Diagnosis Study (19891994)
Number of Arrests and Incarcerations (N=203)
60
50
40
30
20
10
0
Beginning
6 months
Arrests
12 months
18 months
24 months
30 months
36 months
Incarcerations in Jails or Prisons
Arrests and Incarcerations decline as persons treated for dual
disorders recover from substance abuse.
Evidence-Based Practices
Copyright West Institute
NH Dual Diagnosis Study (19891994)
Median Treatment Costs: Patients in Recovery (N=54)
$ 14,000
$ 12,000
$ 10,000
$ 8,000
$ 6,000
$ 4,000
$ 2,000
$0
Begi nni ng
6 months
12 months
Inpatient
18 months
24 months
30 months
36 months
Outpatient
1. Median treatment costs decline more for persons in recovery.
2. Inpatient costs decrease.
3. There is a shift to community based treatment.
4. Those who are most successful often begin with higher than
average treatment costs. Copyright West Institute
Evidence-Based Practices
How do people obtain remission
from dual disorders?




Stable housing
Sober support network/family
Regular meaningful activity
Trusting clinical relationship
• Alverson et al, Com MHJ, 2000
Evidence-Based Practices
Copyright West Institute
Treatment factors for
recovery





Integration of mental health and substance
abuse treatment
Stage-wise interventions
Assertive outreach
Motivational counseling
Substance abuse counseling
Evidence-Based Practices
Copyright West Institute
Principles of Integrated
Dual Disorder Treatment

Integrated
• Same team of dually trained people
• Same location of services
• Both disorders treated at the same time

Stage-wise services
• Different services offered at different stages of
treatment
Evidence-Based Practices
Copyright West Institute
Principles - Stagewise
treatment

Precontemplation - 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, skills
training, family support, self help groups

Maintenance - Relapse prevention
• Relapse prevention plan, continue skills building in active
treatment, expand recovery to other areas of life
Evidence-Based Practices
Copyright West Institute
More treatment factors for
recovery

Social support interventions
• (groups, self help, family)


Long term perspective
Rehabilitation of skills
• (coping, social, leisure, work)


Cultural sensitivity and competence
Program fidelity
Evidence-Based Practices
Copyright West Institute
Recovery model





Consumer driven
Unconditional respect and compassion
Clinician responsible for helping client with
motivation for treatment
Focus on client goals and function, not on
adherence to treatment
Client choice and shared decision making are
important
Evidence-Based Practices
Copyright West Institute
IDDT improves
outcomes
McHugo et al, 1999
Evidence-Based Practices
Copyright West Institute
Program implementation:
15 years in several states



60% of programs attain successful
implementation
High fidelity to model leads to good outcomes
Without focus, fidelity erodes over time
Evidence-Based Practices
Copyright West Institute
Systems Issues
• How to integrate treatments?
• Stages of implementation: motivating, enacting,
and sustaining
• Each stage 6 months - 1 year
• Changes at 5 levels





(1) Health authority
(2) Program leadership
(3) Clinician/supervisor
(4) Family
(5) Consumer
Evidence-Based Practices
Copyright West Institute
Strategies for policy
makers






Building consensus for the vision of integrated
dual disorder services
Conjoint planning
Define standards
Structural, regulatory, reimbursement, and
contracting mechanisms
Demonstrations
Training and monitoring
Evidence-Based Practices
Copyright West Institute
Strategies for program
leadership







Consensus and vision
Specific leader
Train all clinicians
Comprehensive integration
Records
Outcomes
Quality assurance
Evidence-Based Practices
Copyright West Institute
Strategies for clinicians
and supervisors



Outcome based supervision
Knowledge base
New skills
• Assessment
• Motivational treatment
• Substance abuse counseling


Specialty training
Secondary strategies
Evidence-Based Practices
Copyright West Institute
Strategies for
families/supports





Information
Support
Collaboration
Skills and reinforcement
Advocacy and involvement
Evidence-Based Practices
Copyright West Institute
Strategies for consumers






Information
Peer discussion
Counseling
Rehabilitation
Training
New roles - life is more persuasive than
research
Evidence-Based Practices
Copyright West Institute
Conclusions




Implementation of integrated dual disorder
treatment is challenging but critical to
outcomes
Multiple strategies are helpful
3 stages for implementation: motivating,
enacting, and sustaining
Include all stakeholders
Evidence-Based Practices
Copyright West Institute