Transcript One Sky Center

ONE SKY CENTER:
Best Practice Behavioral Health
Approaches for American Indians and
Alaska Natives
Elizabeth Hawkins, PhD, MPH
Dale Walker, MD, Patricia Silk Walker, PhD, Douglas Bigelow, PhD, Laura Loudon, MS
Warrior Spirit Conference, Albuquerque, April 22-23, 2004
Overview
 Introduction
 Overview
 AI/AN
of comorbidity issues
comorbidity
 Comorbidity
 Barriers
to One Sky Center
best practices
to integrated treatment
 Solutions
INTRODUCTION TO ONE
SKY CENTER
One Sky Center
 Funded
by SAMHSA (CSAT & CSAP)
 “Envisioned
as an innovative NRC
dedicated to identification and fostering of
effective and culturally appropriate
substance abuse prevention and treatment.”
-Charles Currie, SAMHSA, July 2003
OSC Goals
 Promote
and nurture effective and
culturally appropriate prevention and
treatment
 Identify
and disseminate evidence-based
prevention and treatment practices
 Provide
 Help
training and technical assistance
to expand capacity and improve
quality in behavioral health care services
OSC Partners
Alaska Native Tribal Health Consortium
Tribal Colleges and Universities
One Sky Center
Northwest Portland Area Indian Health
Board
Eastern U.S. Tribal
Consortium
United American Indian
Involvement
National Indian Youth Leadership
Project
White Bison
Jack Brown
Adolescent Treatment Center
Alaska Native Tribal Health
Consortium



ANTHC is a non-profit health organization owned and
operated by Alaska Native tribal governments and their
regional health corporations.
Provides comprehensive services statewide to Alaska
Natives.
Offers:





Medical Center specialty services
Health and sanitation facility development
Training for Alaska Native health professionals
Health system statewide network support
Community and environmental health services
http://www.anthc.org
Jack Brown Youth Treatment Center

Operated by the Cherokee Nation Health Service
and located in Tahlequah, OK


Catchment area is primarily Kansas, Oklahoma, and
Texas
Number of tribes served 1997-2003: 71
CARF accredited, 20-bed co-educational facility for
youth 13-18 years of age
 Usual length of stay is between 30 to 120 days
 Dual Diagnosis approach that targets physical,
mental, emotional, and spiritual growth


Special emphasis on art therapy as a means of health
promotion
National Indian Youth Leadership
Project


A non-profit organization located in Gallup, NM (founder
is McClellan Hall)
Youth development programs include:





Service learning
Experiential learning
Traditional, culturally-derived rites of passage
Academic enrichment
Ongoing projects include:






Project Venture
Walking in Beauty
Web of Life
21st Century Learning Center
Turtle Island Project
Sacred Mountain Learning Center
http://www.niylp.org
United Indian Involvement

A non-profit organization that provides services to the Los
Angeles American Indian community.








The Los Angeles American Indian Health Project
Robert Sundance Family Wellness Center
Robert Sundance Workforce Development Program
Ah-No-Ven (Healing) Home – Youth Regional Treatment Center
American Indian Clubhouse
Seven Generations Child and Family Counseling Center
Native Pathways to Healing
Circles of Care Program
http://www.laindianhealth.com
White Bison Inc.



An American Indian non-profit organization based in
Colorado Springs (founder is Don Coyhis)
Offers sobriety, recovery, addictions prevention, and
wellness/wellbriety learning resources
White Bison’s mission is to assist in bringing 100 Native
American communities into healing by 2010
 The principle underlying White Bison is living in
harmony with natural law
 Ceremonies are used to help individuals and
communities get back into harmony
http://www.whitebison.org
Sample of OSC Current Projects








SAMHSA portfolio project
Best practices consensus panel
Needs assessment of IHS Youth Regional
Treatment Centers
Alaska Behavioral Health Aide program
CAPT and ATTC needs assessment
Recruitment and training of AI/AN professionals
Technical assistance
Development and dissemination of prevention
and treatment resources
OVERVIEW OF
COMORBIDITY ISSUES
Comorbidity Defined
“Individuals who have at least one mental
disorder as well as an alcohol or drug use
disorder. While these disorders may
interact differently in any one person….at
least one disorder of each type can be
diagnosed independently of the other.”
- Report to Congress of the Prevention and Treatment of CoOccurring Substance Abuser Disorders and Mental
Disorders, SAMHSA, 2002
Lifetime History
Mental Disorder
22.5%
Comorbidity
29%
3.1%
1.5%
1.7%
Alcohol Disorder
13.5%
Comorbidity
45%
1.1%
Drug Disorder
6.1%
Comorbidity
72%
Regier, 1990
Prevalence and Pattern of COD
7-10 million Americans are affected each year
 Antisocial personality disorder, bipolar disorder,
and schizophrenia are most likely to coexist with
a substance use disorder
 Individuals with COD have a high prevalence of
trauma histories and related symptoms
 Individuals with COD are more likely to have
cardiovascular disease, cirrhosis, or cancer than
someone without such a diagnosis

Prevalence and Pattern in Youth
Among adolescents entering substance abuse
treatment, 62% of males and 83% of females had
at least one emotional/behavioral disorder
 Almost 90% of those with a lifetime co-occurring
disorder had at least one mental health disorder
prior to the onset of a substance abuse disorder
 Mental disorder likely to occur in early
adolescence, followed by the substance abuse
disorder 5-10 years later

Multiple Diagnoses Increase
 Treatment
 Use
seeking
of services
 Likelihood
of no services
 Treatment
costs
 Poor
outcome
 Suicide
risk
Affective Disorders and SUD





56% of people with Bipolar Disorder have a
substance use disorder
32% of people with other affective disorders have
a substance use disorder
~20% of youth with depression have history of
substance abuse
15 – 75% of patients in substance abuse treatment
have affective disorder
Use of TCAs and SSRIs show hope for treating
affective disorder and reducing alcohol and drug
intake
Schizophrenia and SUD





47% have substance use disorders
Alcohol use may decrease negative symptoms
(depression, apathy, anhedonia, passivity and
withdrawal)
May also decrease positive symptoms of
hallucinations and paranoia
Schizophrenics often use and abuse stimulants
Drug-induced psychosis marked by prominent
hallucinations or delusions
Anxiety Disorders and SUD





27% have a substance use disorder
Anxiety disorders may be treated with TCAs,
SSRIs and Benzodiazepines (with caution)
Generalized anxiety disorder: Buspirone shown to
treat anxiety and reduce alcohol consumption
Social anxiety is a big risk factor for alcohol and
drug use
With PTSD, people will often use drugs or alcohol
to sleep and stop recurrent nightmares, or to
reduce anxiety
Disruptive Disorders and SUD
23% of people with ADHD have a substance use
disorder
 Combination of ADHD and CD place a child at
greater risk of substance abuse than either one
alone




The greater the number of CD symptoms, the more
severe the substance abuse is likely to be
When CD precedes substance abuse, youth are at
highest risk for ongoing delinquency and drug use in
adulthood
Stimulants are a primary treatment choice but risk
of abuse is high
Rates of Treatment by Type and Severity
Level of the Disorder
Level of Mental Disorder
Level of Substance
Abuse Disorder
12-month substance
dependence
12-month substance
abuse
12-month serious
mental illness
12-month other
mental illness
Neither MH nor SA
29%
71%
MH only
49%
25%
SA only
3%
1%
Both MH and SA
19%
4%
Neither MH nor SA
51%
78%
MH only
49%
19%
SA only
0%
0%
Both MH and SA
0%
3%
Type of Treatment
COMORBIDITY AMONG
AMERICAN INDIANS
AND ALASKA NATIVES
American Indians
 Have
same disorders as general population
 Greater prevalence
 Greater severity
 Much less access to treatment
 Cultural relevance more challenging
 Social context disintegrated
Mental Health:
Culture, Race and Ethnicity





American Indians:
Less likely to receive needed mental health
services
Often receive a poorer quality of mental health
care
Are underrepresented in mental health research
Have more homelessness and incarceration
Have more trauma exposure, suicide, homicide
Trends among AI/AN Youth

Lifetime substance use rates are similar to non-Indian
teens, but AI/AN youth are more likely to:

Use tobacco, inhalants, alcohol, and marijuana daily

Consume alcohol in a binge-drinking style

Engage in high risk behaviors and experience harmful
consequences

AI/AN youth tend to initiate substance use at a younger
age

Higher rates of polysubstance use

Substance use often does not follow the “Gateway” model

Highest rates of emotional/behavioral problems and
suicide
Alcohol and Other Drug Use
 May
cause or mimic psychiatric symptoms
 May initiate or exacerbate a psychiatric
disorder
 Can mask psychiatric symptoms
 May last for days to weeks
 Drug-induced psychiatric symptoms may
clear spontaneously
Inpatient Psychiatric Care/100,000
National
AI/AN
Asian
Black
Hispanic
Total
44
99
23
171
63
Male
56
78
13
123
46
Female
32
21
10
48
21
SAMHSA, 2000
Native American Admissions, 1999
Admissions (Thousands)
Total Male Female
43.2 28.2 15.0
Primary Substance
Alcohol
Marijuana
Opiates
Cocaine
Stimulants
Other
Total
(percent)
62.2 65.7 55.6
12.4 13.0 11.4
9.0 8.0 10.8
6.4 5.0
8.9
5.4 4.0
8.2
4.7 4.5
5.0
100.0 100.0 100.0
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
Past Year Illicit Drug Use
Total Female Male
Total
11.9
9.8
14.1
Native American
19.8
23.3
15.6
Non-Hispanic White
11.8
9.9
13.9
Non-Hispanic Black
13.1
10.2
16.6
Hispanic – Central American
5.7
4.2
7.7
Hispanic – Cuban
8.2
5.5
11.4
12.7
9.2
15.8
Hispanic – Mexican
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
Prevalence of Alcohol Dependence
Total Female Male
Total
3.5
2.1
4.9
Native American
5.6
6.8
4.3
Non-Hispanic White
3.4
2.2
4.8
Non-Hispanic Black
3.4
2.0
5.2
Hispanic – Central American
2.8
0.8
5.4
Hispanic – Cuban
0.9
0.5
1.3
Hispanic – Mexican
5.6
2.6
8.4
Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).
COMORBIDITY BEST
PRACTICES
Best Practices
“Examples and cases that illustrate the use of
community knowledge and science in
developing cost effective and sustainable
survival strategies to overcome a chronic
illness.”
- WHO
Service Planning Guidelines
1.
Dual diagnosis is an expectation, not
an exception.
Service Planning Guidelines
1.
Dual diagnosis is an expectation, not an
exception.
2.
People with COD can be organized
into 4 subgroups for service planning
purposes.
Co-occurring Disorders by Severity
High
Severity
Low
Severity
III
Less severe
mental disorder/
more severe
substance abuse
disorder
IV
More severe
mental disorder/
more severe
substance abuse
disorder
I
Less severe
mental disorder/
less severe
substance abuse
disorder
II
More severe
mental disorder/
less severe
substance abuse
disorder
Mental Illness
High
Severity
Service Planning Guidelines
1.
2.
3.
Dual diagnosis is an expectation, not an
exception.
People with COD can be organized into 4
subgroups for service planning purposes.
Treatment success involves formation
of empathetic, hopeful, integrated
treatment relationships.
Service Planning Guidelines
Dual diagnosis is an expectation, not an
exception.
2. People with COD can be organized into 4
subgroups for service planning purposes.
3. Treatment success involves formation of
empathetic, hopeful, integrated treatment
relationships.
1.
4.
Treatment success is enhanced by
providing interventions for both
disorders continuously across
multiple treatment episodes.
Unified Services Plan
Case management should address:
 Mental health
 Education/vocation
 Leisure/social
 Parenting/family
 Housing
 Financial
 Daily living skills
 Physical health
Service Planning Guidelines
Dual diagnosis is an expectation, not an exception.
2. People with COD can be organized into 4
subgroups for service planning purposes.
3. Treatment success involves formation of
empathetic, hopeful, integrated treatment
relationships.
4. Treatment success is enhanced by providing
interventions for both disorders continuously
across multiple treatment episodes.
1.
5.
Integrated dual diagnosis-specific
interventions are recommended.
Service Planning Guidelines
6.
Interventions need to be matched to
diagnosis, phase of recovery, stage of
treatment, and stage of change.
Stages of Change
precontemplation
relapse
contemplation
maintenance
preparation
action
Service Planning Guidelines
6.
Interventions need to be matched to diagnosis,
phase of recovery, stage of treatment, and stage
of change.
7.
Interventions need to be matched
according to level of care and/or
service intensity requirements,
utilizing well-established level of care
assessment methodologies.
Service Coordination by Severity
High
Severity
Low
Severity
III
Locus of care:
substance
abuse system
IV
Locus of care:
state hospitals,
jails, prisons,
emergency
rooms, etc.
I
Locus of care:
primary
health care
settings
II
Locus of care:
mental health
system
Mental Illness
High
Severity
Service Planning Guidelines
Interventions need to be matched to diagnosis,
phase of recovery, stage of treatment, and stage
of change.
7. Interventions need to be matched according to
level of care and/or service intensity
requirements, utilizing well-established level of
care assessment methodologies.
6.
8.
There is no single correct dual
diagnosis intervention or program.
Intervention must be individualized.
Service Planning Guidelines
6.
7.
8.
9.
Interventions need to be matched to diagnosis,
phase of recovery, stage of treatment, and stage
of change.
Interventions need to be matched according to
level of care and/or service intensity
requirements, utilizing well-established level of
care assessment methodologies.
There is no single correct dual diagnosis
intervention or program. Intervention must be
individualized.
Outcomes of treatment interventions
are similarly individualized.
Treatment Models
 Sequential
treatment: First one provider,
then the other
 Parallel
treatment: Two separate providers
at the same time
 Integrated
treatment: Both services
provided by same clinician or group of
clinicians
Integrated Treatment
“Any mechanism by which treatment
interventions for co-occurring disorders are
combined within the context of a primary
treatment relationship or service setting.”
-CSAT
Effective Interventions for Adults









Cognitive/Behavioral Approaches
Motivational Interventions
Psychopharmacological Interventions
Modified Therapeutic Communities
Assertive Community Treatment
Vocational Services
Dual Recovery/Self-Help Programs
Consumer Involvement
Therapeutic Relationships
Effective Interventions for Youth
 Family
Therapy
 Multisystemic Therapy
 Case Management
 Therapeutic Communities
 Circles of Care
NIDA Recommended Approaches
 Contingency
 Relapse
Management
Prevention Therapy
 Community
Reinforcement Approach
 Motivational
Enhancement Therapy
BARRIERS TO
INTEGRATED
TREATMENT
Disconnect Between Systems
 Professionals
are undertrained in one of
two domains
 Patients are underdiagnosed
 Patients are undertreated
 Neither integrates well with medical and
social service
Difficulties of Integrated Approach
 Separate
funding streams and coverage
gaps
 Agency turf issues
 Different treatment philosophies
 Different training philosophies
 Lack of resources
 Poor cross training
 Consumer and family barriers
Agencies Involved in Health Services
 Indian
Health Services
 Bureau
of Indian Affairs
 Tribal
health programs
 Urban
Indian health programs
 County
and state agencies
Reasons for lack of partnership








Stigma
Limited access
No critical mass
Time
Cost
Competing priorities
Disparate agenda
History of unsuccessful collaboration
SOLUTIONS
Identify Best Practices
Best Practice
Mainstream
Practice
Clinical/services
Research
Traditional
Healing
World Conference on Science
Recommended that scientific and indigenous
knowledge be integrated in
interdisciplinary projects dealing with
culture, environment and chronic illness.
- 1999
Partnered Collaboration
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
What makes a partnership work?
 Trust
– do away with stereotypes
 Real participation at all levels
 Build in incentives for all stakeholders
 Education and training of all
stakeholders
 Dissemination of knowledge
 Enhanced communication
 Social to scientific interaction
Circle of Care
Traditional
Healers
Primary Care
A&D
Programs
Best
Practices
Prevention
Programs
Child &
Adolescent
Programs
Boarding
Schools
Colleges &
Universities
Emergency
Rooms
Resources






National Clearinghouse of Alcohol and Drug Information
(NCADI)
 http://www.health.org
National Institute of Alcohol Abuse and Alcoholism
(NIAAA)
 http://www.niaaa.nih.gov
National Institute of Drug Abuse (NIDA)
 http://www.nida.nih.gov
National Institute of Mental Health (NIMH)
 http://www.nimh.nih.gov
Treatment Improvement Protocol (TIP) Series
 (800) 729-6686
Monitoring the Future Study
 http://www.monitoringthefuture.org
For more information, contact:
Elizabeth Hawkins, PhD, MPH
One Sky National Resource Center
503-494-3703
[email protected]
Visit us online at www.oneskycenter.org