Co-Occurrence: Bridging the Gap for Change

Co-Occurrence: Bridging the Gap for Change

The Next Step

Statewide Task Force On Dual Diagnosis

Final Report And Recommendations

Submitted by:

Dual Diagnosis Recovery Network

On behalf of the State of Tennessee Co-occurrence Task Force

February 15, 2002

Co-Occurrence: Bridging the Gap for Change –

The Next Step

Table Of Contents

Participants

Overview

A.Executive Summary

B.Introduction

C.State History on Co-occurring Disorders

D.Task Force Key Outcomes: State Consensus and Regional Issues

Area 1: Education/Recognition of Need

Area II: Policy

Area III: Provider Capabilities

Area IV: Oversight

Area V: Research and Evaluation

E.Background and Literature Review Supporting the Extent of the Problem

Appendix 1: Family and Consumer Illustrations of Co-Occurrence Treatment Needs

A Parent’s Story

Shelley’s Story

My Story

A Family’s Story

Appendix 2: Position Papers

Tennessee Association of Mental Health Organizations

Moccasin Bend Mental Health Institute

Helen Ross McNabb Center, Inc.

The Region III Provider Task Force on Co-occurring Disorders

Knox Area Rescue Ministries

Peninsula Behavioral Health Position Paper

Frayser Mental Health Center

Tennessee Voices for Children

Centerstone Community Mental Health Center

Ridgeview Psychiatric Hospital and Center, Inc.

Appendix 3: Synopsis Reports by Region and Topic

Appendix 4: Work Group Discussion Outline

Appendix 5: Literature Citations

Appendix 6: Supportive Documentation

Dual Diagnosis Recovery Network

Task Force on Co-Occurrence Statewide Membership

Participants

LoriAbbott, Tennessee Mental Health Consumers’ Association

KimberlyAvant, Friendship House Knoxville

MarianBacon

EricBaker

CynthiaBarker, AdvoCare of Tennessee

KathyBenedetto, Frontier Health

Bob Benning, Ridgeview Psychiatric Hospital and Center

JodiBensley, A.I.M. Center

AnitaBertrand, Mental Health Association of Tennessee

DottieBlades, Frontier Health

MicheleBostwick, Fortwood Center

DavidBowers, Frontier Health

MelanieBoyd, Silver Linings

ChereBradshaw, Behavioral Health Initiatives

LynnBridgman, Tennessee Mental Health Consumers’ Association

NormaBrinkley,Tennessee Mental Health Consumers' Association (Board of Directors)

CatherineBrunson, Metropolitan Drug Commission

BeckyBuckosh, NAMI Sumner County

BillBullington, AdvoCare of Tennessee

GloriaBulloch, Moccasin Bend Mental Health Institute

AnneBurnett Young, Community Development Peninsula Village

MattCallihan

Valley Behavioral Health

KimberlyCampbell

JimCarter, AdvoCare of Tennessee

MichaelCartwright, Foundations Associates

PatCaruthers

NanCasey, Tennessee Christian Medical Center

PatriciaChesnut, Frontier Health

BradleyChipman

RayCleek, Tennessee Christian Medical Center

MarilouCoats, Region III Monitoring & Evaluation Committee

Dual Diagnosis Recovery Network

Task Force on Co-Occurrence Statewide Committee

Sue Coffey-Ramsey, Comprehensive Community Services

LindaCohen, NAMI Nashville

HankConnor, Parthenon Pavilion

PatriciaCooper

MichaelCoppol, Memphis Mental Health Institute

CarlCounts, Frontier Health

CarolCox, Director, Ridgeview Psychiatric Center

KimCudebec, Woodridge Hospital

DavidCunningham, Family Psychiatrics PC; TAADAC

BonnieCurrey, A.I.M. Center & Comprehensive Community Care

RobertCurrie, Alcohol & Drug Council of Middle Tennessee

DeborahDangerfield, Elam Mental Health Center,Meharry Medical College

SarahDavis, James A Quillen VA Medical Center

SharonDavis, Frayser Family Couseling

SunnyDay, Ridgeview Psychiatric Hospital & Center

AlDehart, Comprehensive Community Care

JohnDennis, Foundations Associates

KarenDennis, ACARC

SitaDiehl, Vanderbilt University

AmyDilworth, Tennessee Protection & Advocacy

RandolphDupont, UT Med Psych Svc

ArtDuvall

SherryFalkner, NAMI Tennessee

Jim Ferrell, Comprehensive Community Care

Donna Fisher, Metropolitan Drug Commission

GregoryFisher, Friends Helping Friends

DebbieFollis, Foundations Associates

PatFriedman, Delta Medical Center

JaneFurlong-Cahill, Region III Monitoring & Evaluation Committee

MaribelGadams, NAMI Tennessee

ElliottGarrett, Metro Health Department

JeanGay-Asher, Frontier Health

DavidGettys, Tennessee Mental Health Consumers’ Association

ButchGlover, Jackson Area Council on Alcoholism and Drug Dependence

Melissa H. Goldsmith, The Crisis Center (Division of Family Services of the Midsouth)

MaryGormley, Park Center

LeasaGraham, Volunteer Ministry Center

SueGrant

JenniferGreen, Centerstone Community Mental Health Center

JimGriffin, Tennessee Voices For Children

JoeGuenry, The Hope House

DavidGuth, Centerstone Community Mental Health Center

BarryHale, Quinco Behavioral Health

PattiHall, Helen Ross McNabb Center

TonyHalton, National Health Care For the Homeless

BettyHamilton

TimHamilton, Foundations Associates

LynnHancock

VickieHarden, Foundations Associates

DouglasHarr, Jackson Area Council on Alcoholism and Drug Dependence

DianaHay, Tennessee Mental Health Consumers’ Association

Mary AnnHea, Metro Client Services

DeborahHillin, Buffalo Valley

BettieHinson, NAMI Cumberland County

EvansHinson, NAMI Cumberland County

PaulaHopper, Serenity Recovery Centers

LauraHoward, Hope of East Tennessee

DanielHoyle, The Pathfinders, Inc.

AliceHubbert, Southeast Mental Health Center

PatHumphreys, Frontier Health

SueIngram, Professional Counseling Services

Deanna Irick, Magnolia Ridge

RodJackson, Steps House

SunrayJacobs

JerryJenkins, Volunteer Behavioral Health Care Services

SteveJenkins, Helen Ross McNabb Center

RandallJessee, Frontier Health

RoseJohnson

BarbaraJohnson, AdvoCare of Tennessee

CatherineJones, El Shaddai

RebeccaJoslin, Tennessee Commission on Aging & Disability

RodgerJowers, Tennessee Commission On Children & Youth

DougKing, Peninsula Lighthouse

DeanaKinnaman, Samaritan Recovery Community

FrankKolinsky, E.M. Jellinek Center; Tennessee Association of Alcohol and Drug Abuse Services

KellyLang-Ramirez, Tennessee Association of Mental Health Organizations

NancyLawhead, Memphis Mayor’s Office

DeniseLester, Baptist Memorial Hospital of Union City

ConnieLevenhagen, Tennessee Mental Health Consumers’ Association

ElizabethLittlefield, Western Mental Health Institute

Catie Lott, Moccasin Bend Mental Health Institute

DebbyLovin-Buuck, AdvoCare of Tennessee

LisaLund, Tennessee Voices For Children

JohnMartens, Middle Tennessee Mental Health Institute

TrumanMasters, Aspell Recovery Center

CathyMcCaughan, Tennessee Voices For Children

DougMcCormick, Thasay

SherylMcCormick, Foundations Associates/The Dual Diagnosis Recovery Network

LindaMcDaniel, Friends & Company

ReveMcDavid, Comprehensive Community Services

MamieMcKenzie, Tennessee Voices For Children

MikeMcLoughlin, Memphis Recovery Centers

CarterMiller, Cherokee Health Systems

LindaMobley, AdvoCare of Tennessee

PhilipMorrison, AdvoCare of Tennessee

EstherMoser, Pathways

JaneMynatt, Volunteer Drop-In Center

VickiNeal, The Pathfinders Inc.

AnnNolen, Alliance for the Mentally Ill , Memphis

MimiOrange

AlOrr

EmilyOrr, Foothills Drop-In Center

JoePage, Frontier Health

TinaPatania, Centerpointe

StevePatterson, Aspell Recovery Center

DottiePeagler, NAMI Knoxville

GenePool, NAMI Tennessee

KeithPotts, Centerstone Community Mental Health Centers

LisaPrimm, Mental Health Association of Tennessee, TennCare Partners Advocacy

EvetteReed-Higgs, Behavioral Health Initiatives

JudyReeves, Centerstone Community Mental Health Center

BudRegan, Fortwood Center

AllenRichardson, Serenity Recovery Center

KeithRichardson, U.S. Department of Housing and Urban Development

DebraRogers, Agape, Inc.

Carol AnnRupeka, Comprehensive Communty Care

FredSackleh, NAMI Coffee County

MaggieSamuchin, NAMI Nashville

PaulaSandidge, M.D., National Mental Health Association (Board of Directors)

SherrySchedler, Memphis/Shelby Co Juvenile Court

MarySchneider, Rutherford County Drug Court

Herschel Schwartz, Ph.D., Frayser Family Counseling Center

JackieScott, Jack Geans Shelter

JenniferScroggins-Flaherty, Comprehensive Community Care

BillSewell, Western Mental Health Institute

TerryShapiro, Council for Alcohol and Drug Abuse Services

MarySimons, A.I.M. Center

ErinSkaff, U.T. Medical Psychiatric Services

Amanda Smart, Foundations Associates

CalvarettaSmith, Tennessee Protection & Advocacy

DemetriaSmith, Comprehensive Community Care

DanSmith, Volunteer Behavioral Health Care Services

GeorgeSpain, Centerstone Community Mental Health Center

CynthiaSpann, Department of Health, Bureau of Alcohol & Drug Abuse Services

JewelSteele, Tennessee Department of Correction, Deberry Special Needs Facility

DeniseStewart

SamStewart

RozannStewart, Carey Counseling Center

MarySummerhill, BRIDGES Evaluation Project

PamelaSwain, Carey Counseling Center

CherylTalley, Delta Medical Center

JacquesTate, Harbor House

LeeThomas, Lakeshore Mental Health Institute

HenryThomas, Northwest Community Service Agency

TedThompson, Centerstone Community Mental Health Center

H. RogersThomson, Tennessee Association of Alcohol and Drug Abuse Services

JimTolley, Whitehaven Southwest Mental Health Center

SharonTrammell, Grace House of Memphis

KarenTurks-Smith, Tennessee Mental Health Consumers’ Association

CindyTvardy, Frontier Health

BobVanderspek, Department of Mental Health and Developmental Disabilities Office of Consumer Advocacy

LeeVandewalker, NAMI Knoxville

TammyVanns, NAMI Sumner County

JohnVaughn, E.M. Jellinek Center

DavidVincent, Knox Area Rescue Ministries

StephenWatts, Delta Medical Center

Irene Weaver, Ph.D., Department of Health, Bureau of Alcohol and Drug/Department of Mental Health

CynthiaWest, Cherokee Health Systems

DebiWheatley, NAMI Tennessee

RichardWheeler, Delta Medical Center

LoriWigginton, Tennessee Voices For Children

MelissaWilson, Comprehensive Community Care

JuneWinston, Lowenstein House

JeuneWood, Juvenile Court Memphis/Shelby Co

EvelynYeargin, Mental Health Cooperative

Dual Diagnosis Recovery Network

Task Force on Co-Occurrence Statewide Committee

Appreciation to hosts who provided meeting space for regional work groups:

Centerstone Community Mental Health Centers, Inc., Nashville

Clover Bottom Developmental Center, Nashville

Fellowship Evangelical Free Church, Knoxville

Frontier Health, Johnson City

Jackson Area Council on Alcohol and Drug Dependency (JACOA), Jackson

Metro Health Department, Nashville

Moccasin Bend Mental Health Institute, Chattanooga

Tennessee Christian Medical Center, Madison

The Power Center, Memphis

United Way of Knoxville

Dual Diagnosis Recovery Network

Co-Occurrence: Bridging the Gap for Change

The Next Step

Overview

Prevalence

Referred to as co-occurrence or dual diagnosis, people with combined mental illness and substance use (alcohol and drug) diagnoses are a fast growing segment of underserved residents in our communities:

• According to SAMHSA’s most recent Statistics Sourcebook (1998), an estimated 20 million people have some type of substance use disorder in a given year, 8 million people of whom will also have a co-occurring mental health disorder.This comprises 4.7% of the age 15-54 population of the U.S.
• Extending SAMHSA’s national prevalence estimates to Tennessee’s statewide population, approximately 179,576 Tennesseans between the ages of 15 and 65 have co-occurring disorders.
• Of those with a substance use disorder during a given year, 42 percent also have a mental health diagnosis (52 percent lifetime). Similarly, of those with a mental health diagnosis in a given year, 21 percent also have a substance use disorder (39 percent lifetime). (SAMHSA Sourcebook, 1998).
• According to the National Comorbidity Study (1991), 56% of all persons aged 15-54 years with a mental or addictive disorder have at least one other co-occurring disorder (Kessler, 1994).
• Adolescents with serious emotional problems are nearly four times more likely to be dependent on alcohol or illicit drugs than adolescents with low levels of emotional problems. (Greenbaum, Foster-Johnson, & Petrila, 1996; Crowely & Riggs, 1999)

Barriers and Consequence Related to Co-occurrence

Increasingly the nation is recognizing that existing systems of care designed to treat people with single diagnoses are far less effective for people with co-occurring conditions, as they:

• Are at increased risk of relapse in recovery, incarceration, depression, suicide, homelessness, HIV/AIDS, and other sexually transmitted and infectious diseases, such as Hepatitis C.
• Have significantly higher physical healthcare costs than consumers with a single disorder (Hoff & Rosenheck, 1999) and are over-represented in both our hospitals and judicial systems.
• Are left with the criminal justice system as the “default” system of treatment. (Cocozza & Skowyra, 2000).
• Are more likely to be refused admission or to be prematurely discharged from treatment facilities in both mental health and alcohol & drug service systems (Ridgely, Goldman & Willenbring, 1990).

Solutions

The Task Force on Co-occurrence isan ad hoc committee of approximately 200 stakeholders who met statewide through a series of forums on co-occurrence that involved over 140 hours of service time. Committed to identifying effective, low level and low cost, high impact solutions, the Task Force was represented by expert constituencies who defined The Next Step in Tennessee’s response to address co-occurrence. Through this document, we request appointment of a legislative subcommittee to evaluate these recommendations and other researched based data to gain understanding of the growing individual and societal impact of co-occurrence on Tennesseans. The composite expertise of the Task Force offers a comprehensive document defining State barriers to effective services and treatment, along with tangible recommendations for change to meaningfully impact this underserved and growing population.

A.Executive Summary

D

ual Diagnosis or co-occurrence means that an individual simultaneously experiences both a substance use disorder and one or more psychiatric illnesses. Co-occurrence affects at least 8 million U.S. residents each year, and the incidence of co-occurring conditions continues to increase at an alarming rate -- overloading the nation’s public health and criminal justice systems. Based on extrapolation of SAMHSA’s national data to the State of Tennessee, there are an estimated 179,576 Tennessee residents between the ages of 15 and 65 suffering from co-occurring disorders. Approximately 27% of youth entering Tennessee publicly funded substance abuse programs meet criteria for co-occurring substance abuse and serious emotional disorders, and roughly 12,000 adolescents have potential co-occurring disorders and are in need of more in depth screening (Flowers, 2002). Mental Tennessee Mental Health Institute reports that 52% of individuals admitted have dual diagnoses (Martens, 2001), and Kenneth Minkoff, one of the nation's leading experts on co-occurring psychiatric and substance disorders, states that co-occurrence is the “expectation, not the exception.”

People suffering from co-occurring disorders are disproportionately represented among the poor, homeless, hospitalized, and incarcerated populations. The Substance Abuse and Mental Health Services Administration (SAMHSA) cites that 10% of the public healthcare population account for 71% of our nation’s healthcare costs. SAMHSA indicates that as many as two-thirds of that top 10% are diagnosed with co-occurring mental health and substance use disorders (Buck, 2001, CMHS Office of Managed Care). People with co-occurring conditions have significantly higher physical healthcare costs than consumers with a single disorder (Hoff & Rosenheck, 1999) and are over-represented in both our hospitals and judicial systems. Because people with co-occurring conditions are more likely to be refused admission or to be prematurely discharged from treatment facilities in both mental health and alcohol & drug service systems (Ridgely, Goldman & Willenbring, 1990), the criminal justice system has becomethe “default” system of treatment. (Cocozza & Skowyra, 2000).

Treatment innovations for individuals with psychiatric conditions and addictive disorders have occurred over recent years on separate but parallel paths. This separation, with a distinct lack of a coherent system of connection and collaboration between the two separate systems of care, has had substantial ramifications at both the system level (difficulty merging services and developing integrated programs), and at the individual client level for people who experience co-occurring conditions. Despite consistent evidence regarding the needs for people with co-occurring disorders to receive coordinated, comprehensive and integrated services, they are too often told they must receive treatment from two separate providers or teams of providers. Unfortunately, individuals sometimes find themselves excluded from one or both systems because of complicating features of one or a combination of their disorders.

Most recently, there has been increasing national imperative to develop strategies that reduce both individual and societal costs associated with co-occurrence. Examples of some of these initiatives include:

• Federally, collaboration between the two associations representing State mental health and substance abuse directors occurred through creation of a joint task force that drafted an agreement on financing and delivery of services to people with co-occurring conditions (Mental Health Weekly, 2000).

• Texas developed a Dual Diagnosis Project in response to Senate Concurrent Resolution 88. The project initiated a pilot program to study and evaluate the effectiveness of integrated treatment. The pilot has since expanded to 15 dual diagnosis programs across the state of Texas and has been nationally recognized as an exemplary example of interagency collaboration in the implementation of best practice. Texas also instituted a liaison position to further ensure successful communication between departments as they strive to meet the needs of individuals with co-occurring disorders.

• Oregon’s initiatives regarding co-occurrence included the development of a statewide Task Force to support mutual service enhancements between the Office of Mental Health Services and the Office of Alcohol and Drug Abuse Programs. The Dual Diagnosis Task Force was created in October of 1998 and submitted its final report in May of 2000. This endeavor was the joint work of departmental staff, consumers, families, providers, program administrators, academics and other stakeholders and provided a comprehensive view of systemic needs as well as recommendations to better service individuals with dual disorders.

• New York’s State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York Office of Mental Health (OMH) codified their agencies' intentions to address the needs of the growing numbers of individuals with co-occurring mental health and addiction disorders found in both systems. The 1998 Memorandum of Understanding established an "Interagency Workforce on Co-occurring Disorders" that focused its efforts on: joint screening and assessment; development of joint training curricula; inter-system collaboration at the local level; and the needs of the most severely affected individuals.

Recently a Tennessee Task Force on Co-occurrence, an ad hoc committee of approximately 200 stakeholders statewide, met through a series of forums to evaluate the number of Tennesseans with co-occurring conditions, assess the impact of those conditions, and identify any barriers in obtaining necessary services or treatment. Spending over 140 hours of service time, the Task Force confirmed that state prevalence and barriers to treatment were consistent with that reported on a national level. As such, the Task Force was committed to identifying effective, low level and low cost, high impact solutions to address the needs of our Tennesseans with co-occurring conditions. The Task Force was represented by expert constituencies who defined The Next Step in Tennessee’s response to address co-occurrence. The composite expertise of the Task Force resulted in this comprehensive document that defines State barriers to effective services and treatment, along with tangible recommendations for change to meaningfully impact this underserved and growing population.