An Introduction to Co-Occurring
Disorders
Hon. Peggy Fulton Hora
Judge of the Superior Court of California (Ret.)
LADCP
April 12, 2012
“Frequent flyers” in the justice system
Questions
1.. Have you had a professional experience
where you needed information about an
AOD and mental health issues?
2. What is the percentage of persons whom
you see who have co-occurring mental
health and substance abuse disorders?
3. What is the biggest problem you have in a
court setting handling this type of person?
Mental Illness Defined
 Mental illnesses are medical conditions that
disrupt a person's
o thinking, feeling, mood,
o ability to relate to others
o and daily functioning.
 Just as diabetes is a disorder of the
pancreas, mental illnesses are medical
conditions that often result in a diminished
capacity for coping with the ordinary
demands of life.
NAMI
Addiction is a brain disease…
…with biological, sociological and psychological
components expressed as compulsive behavior.
Why is this topic important to
criminal justice?
• Approximately 5-7% of the U.S. population has a
serious mental illness
• But 14.5 % of men and 31% of women in custody
have a SMI
• 33% of drug court participants have a co-occurring
disorder
•
“Task Force for Criminal Justice Collaboration on Mental Health Issues,” AOC CA 2010
DSM 301.7
Antisocial Personality Disorder
• Pervasive pattern of disregard for and
violation of the rights of others
• Begins in childhood or early adolescence
and continues into adulthood
• Deceit and manipulation are central features
• Impulsivity and disregard of consequences
• 3% males, 1% females general population
• 20-25% for SA tx; 30% criminal offenders
Psychopathy
• Mental disorder marked by affective,
interpersonal, and behavioral abnormalities
• A demonstrated incapacity for empathy and
guilt, impulsivity, egocentricity, and chronic
violations of social, moral, and legal norms
• 3.5% in SA Tx
• 8% in criminal justice system
Largest mental hospital in the U.S.?
Los Angeles County Jail with 3,000 MI inmates every day
Earley, Pete, Crazy: A Father's Search Through America's Mental Health Madness (Putnam, 2006)
Recidivism rates higher
• Recidivism rates for probationers with
mental illness are nearly double (54% vs.
30%)
• Those with MI are more likely to have their
probation revoked than those without
• Parolees have higher violation rates
•
Lorena L. Dauphonot, “The efficacy of community correctional supervision for
offenders with severe mental illness 57 (9-B) Dissertation Abstracts International:
Section B: The Sciences and Engineering 5912 (March 1997)
Crime rates
• Persons with mental conditions report being
under the influence at the time of the
offense in greater numbers than those who
do not have such conditions
Louisiana Numbers
• 183,000 adults live with SMI and about
49,000 children live with serious mental
health conditions
• In 2008, approximately 9,100 adults with
mental illnesses were incarcerated in prisons
in Louisiana
• Public mental health system provides services
to only 17 percent of adults who live with
• serious mental illnesses in the state
NAMI State Advocacy 2010
Grading the State
“D”
“D”
“D”
“Grading the States 2009,” NAMI
• Health Promotion and
Measurement: D
• Financing & Core
Treatment/Recovery
Services: D
• Consumer & Family
Empowerment: D
• Community Integration and
Social Inclusion: D
Who do we see in court?
• People with significant multiple drug
problems
• People with psychiatric disorders that can
benefit from medication, including
psychotic disorders
• People whose accommodation and general
life functioning is brittle
• High risk, high need on Risk/Need
Assessment instruments
Lethality
• According to U.S. Justice Department statistics,
15.8 percent of the defendants in cases of children
killed by a parent had a history of untreated mental
illness.
• People with SMI commit 5,000 suicides and 5% of
all homicides in the U.S.
Shortage of hospital beds for MI
• For every 20 public psychiatric beds in the
US in 1955, there is only one today
• “Untreated persons with severe mental
illness have become major problems in
homeless shelters, jails, public parks, public
libraries and emergency rooms.”
“TAC Study Reveals Severe Shortage of Psychiatric Beds,” Catalyst, Treatment Advocacy Center
(Summer 08)
If punishment won’t work,
• …then what’s a judge to do?
• ASSIGNMENT: Write down alternatives
to “punishment” for people with cooccurring disorders
Incarceration
When you use jail as a
sanction, what happens?
Issues
• Sanctions, Incentives and Treatment
Responses
• Incarceration
• Victim input
• Mental Health Court/docket
• Courtroom Control
• Others?
What is a co-occurring disorder?
• More than one diagnosable illness in the
same individual
• Types of co-occurring: medical,
psychiatric, developmental, etc.
What is a co-occurring substance abuse and
mental health disorder?
•
Substance use, abuse, addiction
•
Plus one (or more) diagnosable mental health
disorders, e.g.,
Bi-Polar
Schizophrenia
Depression
PTSD
1.
2.
3.
4.
“Co-occurring mental
health disorders should be
the expectation, not the
exception.”
Dr. Ken Mincoff
Prevalence of Co-Occurring
Epstein, Joan, et al., “ Serious Mental Illness and Its Co-Occurrence with Substance Use Disorders,” 2002. Office of Applied
Sciences, SAMHSA
Prevalence of Co-occurring
Disorders
• 4.2 million adults (18+ y.o.) have a serious
mental illness (SMI) and a substance use
disorder
• Illicit drug use is more than twice as high
among persons with a SMI than without (27%
to 12.5%)
•
2003 NSDUH data
4 million people with co-occurring
• More than half (52%) receive neither MH or
SA Tx
• Of those receiving tx, 34% receive only MH
• 2% for SA tx
• 12% received tx for both
“4 Million Have Co-Occurring Serious Mental Illness, Substance Abuse,” SAMHSA News (Sept./Oct. 2004)
Co-Occurring Disorders by Severity
Substance Abuse
Low Severity
Mental Illness
High Severity
High Severity
Low to Moderate
Psychiatric Disorders
Low to Moderate Severity
Substance Use Disorder
High Severity Psychiatric
Disorders
Low to Moderate Severity
Substance Use Disorder
Low to Moderate
Psychiatric Disorders
High Severity Substance
Use Disorder
High Severity Psychiatric
Disorders
High Severity Substance
Use Disorder
Co-occurring disorders are expensive
• In central TX in the last 6 years just 9
residents accounted for 2,678 visits.
• One treated in Er > 100 times
• Most have hx of substance abuse and
mental illness
• Cost = $2.7 million
“What an Outrage,” AARP Bulletin (June 2009)
Mental Health + Substance Use
• Each can effect the onset of the other
• E.g., patients with psychotic disorders who smoked marijuana at
an early age developed symptoms almost three years sooner
than those who did not
Matthew Large, et al., “Cannabis Use and Earlier Onset of Psychosis A Systematic Metaanalysis” , Arch Gen Psychiatry. Published online (February 7, 2011)
• Its severity
• E.g., marijuana may contribute to the severity of schizophrenia’s
symptoms (Smesny, et al, ”Cannabinoids influence lipid-arachidonic acid pathways in
schizophrenia,” Neuropsychopharmacology 32:2067-2073, 2007) “Cannabis Could Increase Risks Of
Psychotic Illness By 40 Percent,” Cardiff University (2007, August 1).
Each can mask the other
Which comes first?
• Recent study showed
alcohol abuse may
lead to an increased
risk of depression, not
the opposite
• May be genetic link
•
Fergusson et al., “Tests of Causal Links
Between Alcohol Abuse or Dependence and
Major Depression,” Archives of General
Psychiatry 66 (3) (2009)
Treat Both Disorders
“Ample evidence in the literature
supports the notion that
inadequately treated psychiatric
symptoms interfere with
addiction treatment.”
Co-Occurring Disorder Center
Mentally ill offenders’ re-entry
• Major program components that improve
chance of MI offenders reentering society:
1. Coordinated pre-release planning up to 3
months prior to release
2. Intensive post-release case management
Theurer, Gregory and David Lovell 47(4) Journal of Offender Rehabilitation (2008) 385-406
Re-entry, cont.
• Residential support services
• Community supervision
• Co-occurring tx delivered by mental health
staff with SA training
Some Strategies to Consider
• Use jail sparingly so medication regimes are
not compromised
• Look for creative alternative to
incarceration like ordering the defendant to
set up chairs for peer support group
• Link volunteer work with something
defendant likes to do (work outdoors, work
with animals, etc.)
Strategies, cont.
• Make sure defendant receives integrated
substance abuse and mental health treatment
• Monitor cases closely – community
corrections or the court for high risk/high
need offenders
To reduce recidivism
•
Ask, “Are they managing their illness”?
1.
2.
3.
Going to tx and support groups
Taking meds
Accepting their illness
•
Find an “honest broker” to services.
1.
2.
3.
Reporting deviations from the tx plan
Providing gender and culturally competent tx
Using evidence-based practices
Dave Kelly, Deputy District Attorney, Brooklyn Mental Health Court
WOMEN
Mental health issues
• Co-morbidity complicates
and exacerbates the
problems
• Almost 12% of mothers in
the U.S. has serious mental
illness; 3.2% had SMI + SA
• Up to 95% of parents in tx
programs have co-occurring
disorders
Post Traumatic Stress Disorder
 30-57% women in treatment meet criteria
for PTSD
 45-85% of battered women meet criteria
 Co-morbidity for PTSD and substance use
disorders is 2-3xs higher for females
Trauma-informed Care
• Community corrections, prosecution,
defense and the court must become
“trauma-informed”
• Substance abuse and other mental health
issues are closely associated with trauma
• SA/MH drives the justice system—both
criminal and child abuse and neglect cases
“Understanding women in court,” SAMHSA, Center on Women, Violence and Trauma (2006)
Women with Co-Occurring
Primary Drugs of Choice
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
OAS, 2002
Alcohol
Opiates
Cocaine
Marijuana
Stimulant
Other
Cocaine / Alcohol Abusers with
Comorbid Psychiatric Disorder
MEN
Anxiety
Depression
Bipolar
Panic disorder
Social phobia
PTSD
48%
36%
6%
10%
14%
24%
WOMEN
70%
40%
4%
18%
10%
46%
Men vs. Women in Custody
• Women inmates have
>symptomology
• diagnosed with mental
health problems 3xs rate
of men
Symptoms
Diagnosed
SP
M
SP
F
Jail
M
Jail
F
48%
8%
62%
23%
59%
9%
70%
23%
Women with Co-Occurring More
Likely Than Men to be:
•
•
•
•
•
•
•
Poor
Uneducated
Poor job skills
Receive public assistance
Report more relatives with AOD problems
Care for more dependents
Depressed, anxious, have eating disorders and
lower self-esteem
“Women with Co-Occurring Mental Illness and Substance Abuse,” AIA Center (May 2005)
Jennifer
• Repeated phone calls
to ex
• AOD issues?
• MH issues?
• How do you get the
information you need?
CHILDREN AND ADOLESCENTS
Teens with co-occurring disorders
Addressing Teens’ Issues
• Consider arrest histories of adolescent and
young adult clients
• Coordinate services between MH, juvenile and
criminal justice
• Provide those at high risk with best services
targeted at reducing antisocial behavior
• Provide for continuity of services during ages
16-25
Davis, Maryann, PhD, et al., “Adolescent Mental Health Gender Differences in Arrest Onset & Risk,’ Center for
Mental Health Services Research, U Mass Med. School Issue Brief 5:1 (Jan. 2008)
25 years to grow a mature one
• 18-25 “apprentice
adults”
• Exposure to traumatic
stress can affect
developmental
processes
• Increases risk of SA,
criminal activity,
homelessness and
revictimization
Early onset of use
• Every year before 21
increases likelihood of
problem drinking by
12%
• Early drinkers need
more alcohol to get
high
Adolescent girls
• 1:3 sexually abused by age 16 in U.S.
• Youth aged 12-17 have 2xs rate of violent
victimization than adults
• 2:3 experience direct violence as victims or
witnesses to violence
Another recent survey
showed:
• 1:5 girls have been
sexually or physically
abused
• The abuse occurred at
home (53%)
• It happened more than
once (65%)
• The abuser was a family
member (57%)
• Or a family friend
(13%)
• 29% told no one
• Have increased
likelihood of SA or
eating disorders
Infant and Toddler Mental Health
• 79.8% of children who die of abuse and
neglect were younger than 4
• First year of life the most dangerous
• Mental health risks to infants are magnified;
they suffer disproportionately yet few referrals
are made for children under 5
• 1:5 children in poverty has a diagnosable
mental health disorder
•
“Babies and Toddlers Can Suffer Mental Illness, Seldom Get Treatment,” ScienceDaily (Feb. 23, 2011
Traumatic stress during childhood
•
•
•
•
Can affect physical/mental health
Relationships
School performance
Risk taking in childhood and as an adult
Resources
• SAMHSA Report to Congress on The
Prevention and Treatment of Co-Occurring
Substance Abuse Disorders and Mental
Disorders
http://www.samhsa.gov/reports/co_occur_ho
me.htm
Recommendations to Congress
• “Any door is the right door” to receive
treatment for co-occurring disorders.
• Develop client-centered, individualized
treatment plans based on accurate assessments.
• Ensure the maximum feasible degree of
integration for individuals with the most
serious substance abuse disorders and mental
disorders
• Provide prevention and treatment services that are
culturally competent, age, sexuality and gender
appropriate and that reflect the diversity in the
community.
• Promote the expansion and enhancement of service
providers’ capabilities to treat individuals of all ages
who have co-occurring substance abuse disorders and
mental disorders.
REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF
CO-OCCURRING SUBSTANCE ABUSE DISORDERS AND MENTAL DISORDERS
http://www.samhsa.gov/reports/congress2002/CoOccurringRpt.pdf
Co-Occurring Center for Excellence
COCE http:coce.samhsa.gov
• “Providing integrated services is
fundamental to providing quality care.
Failure to address co-occurring disorders in
either substance abuse or mental health
programs is tantamount to ignoring the
needs of the majority of participants.”
COCE
• National co-occurring disorders prevention
and treatment cross training and technical
assistance
• Bring together state-of-the-art information
on
prevention and treatment services, best
practices, and other knowledge-based
treatment and evaluation activities
TIP 42 Substance Abuse Tx for Persons with
Co-Occurring Disorders (SAMHSA)
• Key elements for co-occurring disorders in
SA Tx agencies and MH agencies
• Seeks to coordinate MH & SA services for
clients who need both
• Good background and statistics
https://ncadistore.samhsa.gov/catalog/product
Details.aspx?ProductID=16979
Principles of Drug Abuse Treatment for
Criminal Justice Populations
• Comprehensive
assessments should
include mental health
evaluations with treatment
planning for these
problems.
“17 Step” Programs
Dual Diagnosis Anonymous
Dual Recovery Anonymous
Double Trouble in Recovery
Five Steps of Dual Diagnosis
1. We admitted we had a mental illness in
addition to our substance abuse and we
accepted our dual diagnosis
2. We became willing to accept help for both of
our diseases
3. We understood the importance of medical
management, clinical interventions and
therapies and accepted the need for the total
abstinence an sobriety from all nonprescribed drugs and alcohol in our program
4. We came to believe that when our own efforts are
combined with the help of others and GOD as we
understand Him we will develop healthy drug and
alcohol free lifestyles and learn to live at peace with
unresolved problems, which is the basic principle of
serenity
5. In following the Twelve plus Five Steps of Dual
Diagnosis Anonymous, and with the guidance of our
Higher Power, a loving GOD of our own
understanding combined with the help and direction
of our fellow D.D.A., we will maintain healthy drug
and alcohol free lifestyles and help others to achieve
abstinence.
U.S. Conference of Chief Justices
Resolution
• Urged state supreme court chief justices to "take a
leadership role to address the impact of mental illness
on the court system through a collaborative effort
involving stakeholders from all three branches of
government.”
• JLI is coordinated by the Council of State
Governments (CSG) Criminal Justice/Mental Health
Consensus Project and the GAINS/TAPA Center for
Jail Diversion.
Judges' Criminal Justice/Mental Health
Leadership Initiative
• JLI is coordinated by the Council of State
Governments (CSG) Criminal
Justice/Mental Health Consensus Project
and the GAINS/TAPA Center for Jail
Diversion
• CCJ committed to join
Jan. 18, 2006. 50:0
COSIGs
Co-occurring State Incentive Grants
Administered by CSAT and CMHS
• Screen individuals for co-occurring disorders
• Assess the level of severity
• Treat in comprehensive and coordinated
manner
• Train providers to screen, assess and develop
preventive interventions and treatment plans
• Evaluate impact of prevention and treatment
COSIGs, cont.
• $6.5 million in incentive grants available to
states to develop and enhance infrastructure
to improve treatment for co-occurring
disorders
• Average award from $500,000 to $1.1
million per year up to 5 years
Resources
•
•
•
•
GAINS Center
Consensus Project
Judicial Leadership Initiative
Evidence-Based Practices, Drake, et al.,
“Implementing Evidence-Based Practices in Routine Mental Health Service Settings,” Psychiatric
Services 52 (2001)
Resources, cont.
• Bazelon Center for Mental Health Law
• NJC Co-Occurring Substance and Mental
Health Disorders and Managing Cases with
Mental Disabilities courses
(www.judges.org)
• Second Generation of Mental Health Courts
•
Redlich, et al., The Second Generation of Mental Health Courts, Psych.Pub.Pol.Law 11(4) 527-538
(2005)
Resources, cont.
• The Courage to Change: A Guide for
Communities to Create Integrated Services
for People with Co-Occurring Disorders in
the Justice System (National GAINS Center, Dec. 1999)
• MH webliography/AOD listserv
• judgehora@judgehora.com
Resources
Resources