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 to One Sky Center

Overview of comorbidity issues

AI/AN comorbidity

Comorbidity best practices

Barriers 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 training and technical assistance Help to expand capacity and improve

quality in behavioral health care services

National Indian Youth Leadership Project Jack Brown

Adolescent Treatment CenterWhite Bison

Alaska Native Tribal Health Consortium

United American Indian Involvement

Northwest Portland Area Indian Health Board

Eastern U.S. Tribal Consortium

Tribal Colleges and Universities

One Sky Center

OSC Partners

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 Co-Occurring Substance Abuser Disorders and Mental Disorders, SAMHSA, 2002

Lifetime History

Mental Disorder22.5%

Comorbidity29%

3.1% 1.5%

1.7%

1.1%

Alcohol Disorder13.5%

Comorbidity45%

Drug Disorder6.1%

Comorbidity72%

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 seeking

Use 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

Type of Treatment

12-month serious mental

illness

12-month other mental

illness

12-month substance

dependence

Neither MH nor SA 29% 71%

MH only 49% 25%

SA only 3% 1%

Both MH and SA 19% 4%

12-month substance

abuse

Neither MH nor SA 51% 78%

MH only 49% 19%

SA only 0% 0%

Both MH and SA 0% 3%

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

Total Male FemaleNational 44 56 32AI/AN 99 78 21Asian 23 13 10Black 171 123 48Hispanic 63 46 21

SAMHSA, 2000

Native American Admissions, 1999

Total Male FemaleAdmissions (Thousands) 43.2 28.2 15.0

Primary Substance (percent) Alcohol 62.2 65.7 55.6Marijuana 12.4 13.0 11.4Opiates 9.0 8.0 10.8Cocaine 6.4 5.0 8.9Stimulants 5.4 4.0 8.2Other 4.7 4.5 5.0Total 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

Hispanic – Mexican 12.7 9.2 15.8

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

Prevalence of Alcohol Dependence

Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

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

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

IIILess severe

mental disorder/more severe

substance abuse disorder

IVMore severe

mental disorder/more severe

substance abuse disorder

ILess severe

mental disorder/less severe

substance abuse disorder

IIMore severe

mental disorder/less severe

substance abuse disorderA

lco

ho

l an

d o

ther

dru

g a

bu

se

Mental IllnessHigh Severity

Low Severity

High Severity

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.

3. Treatment success involves formation of empathetic, hopeful, integrated treatment relationships.

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.

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.

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

1. 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.

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.

precontemplationprecontemplation

relapserelapsecontemplationcontemplation

maintenancemaintenance

actionaction

preparationpreparation

Stages of Change

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

IIILocus of care:

substance abuse system

IVLocus of care:state hospitals,jails, prisons,emergency rooms, etc.

ILocus of care:

primary health care

settings

IILocus of care:mental health

system

Alc

oh

ol

and

oth

er d

rug

ab

use

Mental Illness

High SeverityLow

Severity

High Severity

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.

8. There is no single correct dual diagnosis intervention or program. Intervention must be individualized.

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.

8. There is no single correct dual diagnosis intervention or program. Intervention must be individualized.

9. 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 TherapyMultisystemic TherapyCase ManagementTherapeutic CommunitiesCircles of Care

NIDA Recommended Approaches

Contingency Management

Relapse 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

Clinical/servicesResearch

TraditionalHealing

MainstreamPractice

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

Research-Education-Treatment

Grassroots Groups

Community-BasedOrganizations

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

Best Practices

Child & Adolescent Programs

Prevention Programs

Primary Care

EmergencyRooms

TraditionalHealers

A&D Programs

Colleges & Universities

Boarding Schools

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

hawkinse@ohsu.edu

Visit us online at www.oneskycenter.org