Key Messages for the Program Level

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Findings from the Synthesis

• From a developmental perspective there are many common risk factors (MH and SUD) and many problems go together

• Many MH and SUD in adolescence persist into later years

• MD in adolescence often predate/predict/contribute to SUD in later life and vise versa

• Ecological approaches work best in other areas when planning and implementing prevention programs

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Implications ……

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Time to address the imbalance of our efforts on co-occurring disorders

Prevention Treatment

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Implications for prevention programming

• Consider co-occurring disorders (and MH and SUD) as key outcomes of community health interventions and community development aimed at determinants of health

• Consider “treatment” and “support” as opportunities for prevention and health promotion – Individual level (e.g, self- esteem, emotional regulation, school

success)– Family level (e.g., parenting, family functioning)

• Consider screening at a population level –schools, primary care/pediatrics, community health

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Implications for prevention programming

• Aim to work at multiple-levels - program efforts should be consistent with work at individual, family, school, community levels (ecological approach)

• Focus on reducing risk factors AND enhancing protective factors (e.g., wellness and resiliency)

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Findings from the Synthesis

• Very low levels of help-seeking among adolescents with co-occurring disorders

• However, those with CD may be more likely to be accessing services than those with single disorders

• Early recognition and treatment reduces long term treatment trajectory (outcome, cost)

• Parents often reluctant to discuss MH and SUD concerns and engage their children in MH and SUD services

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Implications for early interventionprogramming• Anti-stigma work in the community must include a

focus on adolescents and families generally• Recognize value of, and work with, the informal

supports around the young person and the family• Agency practices for intake should acknowledge and

work with the motivation within young people to address their complex problems – is your program CD friendly? Is your program adolescent friendly?

• Work with parents to improve their recognition of MH and SUD and willingness to engage their children in services

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Findings from the Synthesis

• In MH and SUD service delivery settings co-occurring disorders are the rule rather than the exception – rates of overlap are very high for some combinations

• Yet more adolescents with co-occurring disorders are NOT identified than are identified

• The complexity and multiple problem areas negatively impact the outcome of treatment and support – the earlier one intervenes the better

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Implications for screening and assessment• Universal screening for SUD in mental health services

and vice versa in substance use services• Reliable and valid tools are available• Approach/tools need to be tailored to different

settings and the time and resources available• Screening needs to be implemented in a staged

approach (each stage more focused and resource intensive) and considered in context of both assessment and outcome monitoring

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Purposes of Screening

– Improving decision making with specific clients

(decision rules based on cut-off scores are necessary for this. However, screening is also an early step in process of client engagement and tools are meant to complement not replace clinical judgement )

- Managing resources and community linkages –systems planning

– Setting stage for outcome monitoring

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“Screening Framework”

Children Adolescents Adults Older Adults

Developmental PhaseClient Engagement Phase

Screening

Stage 1

Stage 2

Assessment

Outcome Monitoring

Mental health, substance use, problem gambling, traumatic brain Injury, etc etc

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Staged Model of Screening and AssessmentGoal Brief Description

Stage 1: Screening –Tentative identification of generalized caseness

Brief screen for possibility of any substance use or mental disorder

GAIN Short Screener

Stage 2: Screening—Tentative identification of disorder-specificcaseness

Longer screen for specific substance use or mental disorders

DISC Predictive Scales, or POSIT

Stage 3: Assessment—Confirmation of specific disorders

Diagnostic assessment and treatment planning

(e.g., Schedule for Affective Disorders and Schizophrenia for School Aged

Children – Present and Lifetime Version (K-SADS); full GAIN assessment.

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Some General Issues to Consider

• Not all clinicians/workers have the same level of enthusiasm for screening or assessment “tools”. May reflect:– Training/discipline differences– Additional workload– Possible intrusiveness in early stage of relationship

building– Possible overlap with existing assessment tools. Not

our “business”– Unsure what to do with the resulting information

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Have a Screening Response Plan (SRP)• Clinical/program level:

– when to monitor and repeat the screening tool, such as for depression (substance induced)

– suicide risk• System/cross-provider level

– links for referral for crisis (crisis team, ER)– links for referral for assessment (addiction-MH

agency relationships; psychiatry, primary care)

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Using the Results of Screening Tools• Linking motivational interviewing with screening and

using the results

• Ensuring the pathways are in place for referral (and back to your program if needed)

• Knowing when to refer for treatment/support and when referral may not be needed ---- protocols need to be in place around this

• Building capacity to manage some mental health problems (or substance use problems) without referral (e.g., CBT, exercise). Brief interventions, CBT for some substance use problems

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ASSESSMENT (untying the knot)

• Assessment must be seen as ongoing, including a period of abstinence or significant reduction in use. Expertise/training required to sort out this complexity

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Potential relationships between substance use and mental health problems/disorders

• Create - e.g., alcohol is a depressant• Trigger - e.g. cannabis and predisposition to schizophrenia• Exacerbate - e.g., alcohol, depression and suicide• Mimic - e.g., crystal meth and paranoid delusions• Mask – e.g., youth with ADHD may be less distractible when

using cocaine• Independent – both may result from a common cause that

has made them vulnerable

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Other Critical Aspects for Assessment

• Broad bio-psycho-social approach• Sort through program and staff perspectives on the

importance of diagnoses (benefits and potential risks) and how to tap into and support “sub-threshold”disorders

• Incorporate culture based methods as appropriate (e.g., First Nations)

• Incorporate motivational interviewing strategies• Assess treatment motivation but distinguish between

intrinsic motivation and extrinsic sources of pressure• Be strengths-based and solution-focused• Family assessment critical

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Findings from the Synthesis• The complexity and multiple problem areas negatively

impact the outcome of treatment and support• Engagement and program retention are major

challenges• Durable therapeutic alliance is critical• Much more research is needed on value of specific

interventions for specific combinations of CDs• Outcomes likely to be improved if treatment and

support is organized and delivered in an integrated manner

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Findings from the Synthesis• There are many forms and levels of integration

– two levels of services and systems• Co-occurring health problems high in both MH

and SUD populations and they tend to be under-detected and under-managed

• Primary care is the “front line” for both MH and SUD

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Implications for treatment and support

• Consider multi-component programs - reduce the hoops and barriers across small, highly specialized programs

• Allow for flexibility and client choice as much as possible

• Provide integrated MH and SUD services but there are many ways to plan and implement “integration” – in general the degree of integration should depend on the severity and complexity of the situation

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Implications for treatment and support (con’t)

• Service-Level Integration– Clinical and psychosocial services and supports

with shared philosophy and treatment messages, coherent and shared treatment and support planA. Co-located, single team/single site modelB. Collaborative model – multiple providers

including community partners and service agreements, cross-training

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The Importance of Working through Key Principles and Values when Integrating Services

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Expand your Integration efforts

• Policy is moving towards more integration with primary care – some jurisdictions have “arrived” at this broader playing field

• Strengthen your relationship with health services generally, including primary care

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Now need a much broader systems perspective

MH SUCD

Primary Care

EmergencyJustice

Hospital

Street services

Schools

Social Assistance

Housing

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Findings from the Synthesis

• There is a lot we do NOT know about prevention, early intervention and treatment/support for adolescents with co-occurring disorders

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Implications for program evaluation and knowledge exchange

• Have an evaluation plan for existing and new services dedicated to this population, especially “integration” activities

• Become involved in knowledge exchange networks, communities-of-practice and other activities that bring researchers, evaluators and service providers together

THANK YOU!