Vivian B. Brown, Ph.D.PROTOTYPES

Ken Bachrach, Ph.D.Tarzana Treatment Center

Lisa Melchior, Ph.D.The Measurement Group

Introducing the COJAC Screener: A Short Screening Instrument for COD and Trauma

What is COJAC?

• In the summer of 2005, the State Co-Occurring Disorders Workgroup/COD Policy Academy members, along with representatives from the County Alcohol and Drug Program Administrators Association of California (CADPAAC) and the California Mental Health Directors Association (CMHDA), formed the Co-Occurring Joint Action Council (COJAC) to develop and implement the State’s COD Action Plan

The Screening Committee of COJAC

• One of the major objectives of the COJAC State Action Plan was to identify screening protocols designed to meet the needs of a variety of populations served by both AOD and Mental Health Systems, including adolescents, women with children, adults, and transition age youth with trauma

• The Screening Committee was established; chair of the committee is Dr. Vivian Brown

The Screening Committee of COJAC

• The Committee was charged with identifying the best screening tool(s) for COD

• The Screening Committee identified all instruments being utilized across the country; we found that the most widely used instruments were those designed either for identification of substance abuse or identification of mental illness

The Screening Committee of COJAC

• We, therefore, decided to design a California screening tool that not only would identify COD, but would be short enough to not burden clients nor staff, and simple enough to be utilized in a wide range of community service sites (including emergency rooms)

What is the COJAC Screener?

• The Co-Occurring Disorders Screening Instrument is composed of 9 questions:– 3 questions on mental health

– 3 questions on alcohol and drug use

– 3 questions on trauma

• These questions were adapted from the Collaborative Care Project, Canada, and the Co-Morbidity Screen from the Boston Consortium

Pilot Testing

• Pilot testing of the screener was implemented by PROTOTYPES and Tarzana Treatment Center in May 2007; both agencies have Community Assessment Service Centers (CASCs), AOD programs, and mental health programs

• The Screening Committee set the cut point for pilot testing low – at 1 point, in order to test the COJAC Screener with the GAIN Short Screener (SS) and the Addiction Severity Index (ASI)

Pilot Testing

• Tarzana did not use the GAIN – only the ASI; Tarzana piloted the COJAC Screener on 1,386 clients, including 51% AOD clients, 12% CASC, 31% primary care, 5% ER, and 2% high school students

• PROTOTYPES piloted on 365 CASC clients: over 10% had COJAC Screener and GAIN SS; 90% had COJAC and ASI

Select Data from PROTOTYPES

Type of COD with Positive Screen

Frequency Valid Percent Cumulative Percent

None 42 11.5 11.5

MH Only 21 5.8 17.3

AOD Only 95 26.0 43.3

Trauma Only 6 1.6 44.9

MH & AOD 55 15.1 60.0

MH & Trauma 20 5.5 65.5

AOD & Trauma 37 10.1 75.6

MH & AOD & Trauma 89 24.4 100.0

Total 365 100

Select Data from Tarzana

Yes Responses to Mental Health Questions

Primary Care CASC School AOD ER (Medical) OV CASC

15% 24% 42% 47% 63% 70%

Yes Responses to Alcohol and Drug Use Questions

Primary Care CASC School AOD ER (Medical) OV CASC

14% 45% 46% 72% 80% 92%

Yes Responses to Trauma/Domestic Violence Questions

Primary Care CASC School AOD ER (Medical) OV CASC

10% 13% 25% 30% 30% 30%

Pilot Testing Results

• What the Screening Committee was attempting to answer with this first pilot was:1. Will this short screener pick up potential COD and will it

be correlated with longer screening instruments?

2. Will this screener be easy to administer; not burden client nor staff?

3. Are the results good enough to begin implementation?

Question 1: Picking up COD

PROTOTYPES Sample

• More than half of those screened (55.1%), screened positive in at least 2 of the 3 domains

• 30.7% screened positive in 2 domains

• 24.4% screened positive in all 3 domains

• Only 11.5% did not identify problems in any of the 3 domains

Question 1: Picking up COD

Tarzana Sample

• We get an interesting picture of responses across 6 groups; across groups, 76% responded with at least one “yes” response– Primary Care: 4-18% responded positive to all questions; 23%

have been worried about MH

– ER: 52% worried about thinking, etc. (MH)

– Olive View CASC: 79% positive for MH, 90-95% positive for AOD; 53% positive for partner DV

– High School: 40% worried about MH; 31% harmed self or thought of harming self; 42% AOD, 42% partner abuse; 35% physical abuse

Question 1: Correlated with Other Screeners

PROTOTYPES Sample• The 3 MH screening questions appear to have a strong

relationship with the GAIN MH measure (both internal and external) and the ASI psychiatric problem severity

• The 3 AOD questions appear to have a strong relationship with the GAIN substance disorder measure, but minimal to the ASI AOD severity measures

• The 3 Trauma questions appear strongly related to the GAIN crime/violence measure (more than the MH measure) and also appear to relate strongly with the ASI psychiatric problem severity

Question 1: Correlated with Other Screeners

Tarzana Sample• Tarzana data looked at item by item

• Responses to MH COJAC and ASI were in the same direction and chi-square tests were strong

• For AOD, COJAC and ASI, drugs were in the same direction, but alcohol questions were not

• There was only one ASI question to compare COJAC and ASI trauma; responses were in same direction, but not significant

Question 2: Comfort/Not Burdensome

• In discussions with PROTOTYPES staff and Tarzana staff, it appeared that neither staff nor clients were burdened by the COJAC Screener

Question 3: Results Good Enough to Go to Next Steps

• From both pilot sites, the answer appears to be yes

Limitations of Pilot Testing

• While we set the cut point low at 1 “yes,” we do not have data analyzed for negatives; i.e., those people who had zero on COJAC and GAIN data – would GAIN have picked up other problems?

• We did not analyze by gender and this could explain some issues of the trauma questions

Next Steps

• A meeting was held with all CASC directors to discuss the positive results of the pilot testing and possible implementation by all CASCs

• Los Angeles and other Counties have decided to begin implementation of the COJAC Screener, with the cut point raised to a minimum of two “yes” responses – one in MH and one in AOD or one in either MH and AOD and one in trauma

• State ADP is implementing an expanded pilot test of the Screener

The COJAC Screening Committee

• Vivian B. Brown, Prototypes – Chair

• Carmen Delgado, ADP

• Terry Robinson, ADPI

• Tom Metcalf

• Karen Streich, LA County DMH

• Lisa Melchior, The Measurement Group

• Sandy Mills, LA County DMH

• John Sheehe, LA County DMH

The COJAC ScreenerThe COJAC Screener

Albert Senella, Ken Bachrach, Ph.D. Albert Senella, Ken Bachrach, Ph.D. & Clarita Lantican, Ph.D.& Clarita Lantican, Ph.D.

Tarzana Treatment CentersTarzana Treatment Centers

Sixth Annual Conference on Co-Occurring DisordersSixth Annual Conference on Co-Occurring DisordersLong Beach, CALong Beach, CA

February 7, 2008February 7, 2008

Survey Timeframe & Sites Survey Timeframe & Sites

Data collected the entire month of May 2007Data collected the entire month of May 2007 Tarzana Treatment Center sitesTarzana Treatment Center sites

Inpatient detoxInpatient detox 3 adult residential programs in Tarzana, Long Beach and 3 adult residential programs in Tarzana, Long Beach and

LancasterLancaster 1 youth residential program in Lancaster1 youth residential program in Lancaster 2 outpatient programs in Tarzana and Lancaster2 outpatient programs in Tarzana and Lancaster 2 substance abuse assessment centers in Tarzana and 2 substance abuse assessment centers in Tarzana and

LancasterLancaster Northridge Hospital Medical Center ERNorthridge Hospital Medical Center ER Olive View Hospital EROlive View Hospital ER

Survey Participant GroupsSurvey Participant Groups

AODAOD – TTC patients admitted to Detox, Residential and – TTC patients admitted to Detox, Residential and Outpatient programs at all sites.Outpatient programs at all sites.

Primary CarePrimary Care – TTC Family Clinic patients in Tarzana and – TTC Family Clinic patients in Tarzana and Lancaster.Lancaster.

CASCCASC – Clients referred to Community Assessment & – Clients referred to Community Assessment & Service Centers in Tarzana and Lancaster for substance Service Centers in Tarzana and Lancaster for substance abuse assessment.abuse assessment.

ER (Medical)ER (Medical) – Emergency Room patients at Northridge – Emergency Room patients at Northridge Hospital and Olive View Medical Center.Hospital and Olive View Medical Center.

Olive View CASCOlive View CASC – Clients referred to CASC for psychiatric – Clients referred to CASC for psychiatric assessment.assessment.

SchoolSchool – High School students in Lancaster participating in – High School students in Lancaster participating in a substance abuse and HIV prevention project.a substance abuse and HIV prevention project.

Survey ParticipantsSurvey Participants

A total of 1,386 patients/clients A total of 1,386 patients/clients participated in the survey: participated in the survey: 51% AOD patients51% AOD patients 31% primary care clinic patients31% primary care clinic patients 12% Community Assessment & Service 12% Community Assessment & Service

Center (CASC) clientsCenter (CASC) clients 5% ER patients for medical & psychiatric 5% ER patients for medical & psychiatric

carecare 2% high school students 2% high school students

*Responded "yes" to one or more *Responded "yes" to one or more of the 3 COJAC questionsof the 3 COJAC questions

Positive ResponsesPositive Responses** for MH, AOD and Trauma for MH, AOD and Trauma / Domestic Violence Based on COJAC Screen/ Domestic Violence Based on COJAC Screen

   MHMH AODAOD Trauma / Trauma / Violence Violence

   PercentPercent PercentPercent PercentPercent

Primary CarePrimary Care 1515 1414 1010

CASCCASC 2424 4545 1313

SchoolSchool 4242 4646 2525

AODAOD 4747 7272 3030

ER(Medical)ER(Medical) 6363 8080 3030

OV-CASCOV-CASC 7070 9292 3030

Comparison of AOD patient Comparison of AOD patient responses to COJAC and ASI for responses to COJAC and ASI for

similar items similar items Mental HeathMental Heath COJACCOJAC

((n n =697)=697)

ASIASI

((n n =201)=201)

Have you ever harmed yourself or thought Have you ever harmed yourself or thought about harming yourself?about harming yourself? (COJAC)(COJAC) 75%75%Serious thoughts of suicide – lifetime (ASI)Serious thoughts of suicide – lifetime (ASI) 80%80%

AODAODHave you ever had any problem related to your Have you ever had any problem related to your use of alcohol or other drugs? (COJAC)use of alcohol or other drugs? (COJAC) 78%78%Troubled or bothered by drug problems in the Troubled or bothered by drug problems in the past 30 days (ASI)past 30 days (ASI) 77%77%

Findings from Pilot TestFindings from Pilot Test

The comparison between COJAC and ASI of The comparison between COJAC and ASI of MH and SA questions are statistically MH and SA questions are statistically significant. Overall, the responses are in the significant. Overall, the responses are in the same direction. same direction.

The comparison between COJAC and ASI The comparison between COJAC and ASI questions for trauma and domestic violence questions for trauma and domestic violence are not statistically significant. This can be are not statistically significant. This can be explained by the fact that the ASI does not explained by the fact that the ASI does not have a question that is a good match for have a question that is a good match for COJAC questions.COJAC questions.

ConclusionsConclusions

The findings of the survey provide valuable The findings of the survey provide valuable insights on the history of TTC patients/clients insights on the history of TTC patients/clients concerning mental health, AOD and concerning mental health, AOD and trauma/domestic violence issues. trauma/domestic violence issues.

The findings provide TTC the capability to The findings provide TTC the capability to identify the needs of patients/clients as part identify the needs of patients/clients as part of substance abuse treatment. of substance abuse treatment.

The findings provide insights to prioritize the The findings provide insights to prioritize the patients/clients in addressing their needs.patients/clients in addressing their needs.

More importantly, the findings show the More importantly, the findings show the validity of the COJAC tool as a screening tool. validity of the COJAC tool as a screening tool.

COJAC Co-Occurring Disorders Screening Instrument: Pilot Test

Lisa A. Melchior, Ph.D.The Measurement GroupCulver City, California

In collaboration with Vivian B. Brown, Ph.D. and G. J. Huba, Ph.D. with additional contributions from Aaron Griffith, MA and Eva Sofia Mendoza. Pilot study data collection protocols were designed by the COJAC COD Screener Subcommittee.

About these Pilot Test Data

PROTOTYPES collected pilot test data for the COJAC Co-Occurring Disorders Screening Instrument April – May 2007

Data were collected from 365 individuals at the PROTOTYPES SPA 3 CASC locations in El Monte, Pomona, and Pasadena

n = 323 n = 268 with data from the COD screening instrument,

Addiction Severity Index (ASI) composite scores, and ASI severity ratings

n = 34 with data from the COD screening instrument and the GAIN Short Screener (GAIN SS)

Preliminary Validity Evidence

The COD screening items and composites are moderately correlated with ASI and GAIN measures of comparable constructs

Correlations between Co-Occurring Disorders Screening Measures and GAIN Short Screener/Addiction Severity Index Scores Co-Occurring Disorders Screening Measures Mental Health Items Alcohol & Drug Use Items Trauma/Domestic Violence Items Summary Screening Measures

Ever worried about how thinking, feeling, or acting

Others ever concerned about how you were thinking, feeling, or acting

Ever harmed self or thought about harming self

Ever had problem related to AOD use

Others ever concerned about AOD use or suggested cutting down

Ever denied AOD problem to others but felt maybe there is problem

Ever in relationship where pushed or slapped by partner

Ever punched, kicked, choked, or serious physical punishment from parent/other adult before age 13

Ever touched in a sexual way or made to touch someone against will before age 13

Number of responses for Mental Health Screening Questions

Number of responses for Alcohol & Drug Use Screening Questions

Number of responses for Trauma/ Domestic Violence Screening Questions

Total Number of responses Endorsed

ASI Composite Scores (n = 268) Medical .20** .15** .20** -.01 .05 -.05 .02 .19** .12* .23** .00 .14* .18** Employment-

Support .14* .20** .13* .06 .05 .07 .18** .09 .13* .20** .09 .18** .22**

Alcohol .20** .08 .06 .06 .08 .15* -.08 .02 -.03 .15* .14* -.04 .12 Drug .06 .07 -.11 .01 .19** .12 .01 .00 .05 .02 .16** .03 .09 Legal .09 .03 -.02 -.11 .05 .05 .12 .03 .06 .05 .01 .10 .08 Family-Social .13* .06 .20** .02 .02 .03 .12* .13* .14* .16* .03 .17** .17** Psychiatric .46** .40** .46** .03 .09 .09 .13* .34** .30** .56** .11 .33** .47** ASI Severity Ratings (n = 268) Medical .18** .11 .14* -.01 .03 -.09 .02 .11 .07 .18** -.03 .08 .11 Employment-

Support .01 -.11 -.08 .04 -.17** -.19** .05 -.07 .00 -.08 -.18** -.01 -.12

Alcohol .15* -.02 .03 .08 -.08 -.05 -.07 -.05 -.07 .08 -.04 -.08 -.02 Drug .11 .04 -.07 -.02 -.02 -.12* .04 .09 .02 .05 -.08 .07 .02 Legal .09 -.02 -.03 -.11 -.09 -.08 .12* .05 .10 .02 -.13* .12* .01 Family-Social .13* .03 .07 .02 -.13* -.13* .10 .02 .13* .10 -.13* .11 .04 Psychiatric .50** .41** .40** .01 .04 .01 .21** .34** .31** .56** .03 .37** .46** GAIN Short Screener (n = 34) Internalizing

Disorders .48** .33 .16 -.39* .16 .25 .05 .24 .21 .54** -.03 .22 .34

Externalizing Disorders

.29 .24 -.02 -.09 -.09 -.02 .20 .20 -.19 .30 -.09 .09 .14

Substance Disorders

-.06 .01 .18 .62** .43* .37* .18 .07 .22 .04 .60** .22 .42*

Crime-Violence

.20 .15 .65** .27 .55** .37* .47** .17 .32 .47** .48** .45** .66**

Total Disorders .31 .26 .33 .22 .39* .36* .34 .25 .19 .47** .39* .36* .57** ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed). Correlations of measures of similar constructs are shown in bold font. These measures would be expected to demonstrate moderate positive relationships. However, because the full range of data is not available (that is, these only represent cases that endorsed one or more of the primary COD screening items), these statistics may not fully represent the ability of the screening instrument to accurately screen for co-occurring disorders.

Mental Health Screening

The three mental health screening items on the COD screening instrument appear to have a strong relationship with ASI measures of psychiatric problem severity and GAIN mental health measures of internalizing and externalizing disorders

These appear to work well as screening items for mental health issues

AOD Screening

The three alcohol and drug use items on the COD screening instrument appear to relate minimally to ASI alcohol/drug problem severity measures

There are stronger relationships between the alcohol and drug use COD screening items and the GAIN SS substance disorders measure

Trauma/DV Screening

Similar to the mental health items, the three trauma/domestic violence items on the COD screening instrument also appear to relate strongly to ASI measures of psychiatric problem severity

However, they differentiate with respect to the GAIN SS The COD trauma screening items have stronger

relationships with the GAIN SS Crime/Violence measure than with the mental health measures (for internalizing and externalizing disorders)

This is an important distinction that is consistent with constructs of trauma/domestic violence

Screening Composite Scores

Composite scores were formed for each of the content areas in the COJAC COD screener Count of number of items answered “yes” within

each domain Mental Health (0-3) Alcohol/Drug Use (0-3) Trauma/Domestic Violence (0-3)

Plus total score across all nine items (0-9)

COD Screener Summary Scores and ASI Composite Scores

Mental Health Items

Alcohol & Drug Use

Items

Trauma/DV Items

Total Score

Medical .23** .00 .14* .18**

Employment .20** .09 .18** .22**

Alcohol .15* .14* -.04 .12

Drug .02 .16** .03 .09

Legal .05 .01 .10 .08

Family-Social .16* .03 .17** .17**

Psychiatric .56** .11 .33** .47**

n = 268

COD Screener Summary Scores and ASI Severity Ratings

Mental Health Items

Alcohol & Drug Use

Items

Trauma/DV Items

Total Score

Medical .18** -.03 .08 .11

Employment -.08 -.18** -.01 -.12

Alcohol .08 -.04 -.08 -.02

Drug .05 -.08 .07 .02

Legal .02 -.13* .12* .01

Family-Social .10 -.13* .11 .03

Psychiatric .56** .03 .37** .46**

n = 268

COD Screener Summary Scores and GAIN Short Screener

Mental Health Items

Alcohol & Drug Use

Items

Trauma/DV Items

Total Score

Internalizing Disorders

.54** -.03 .22 .34

Externalizing Disorders

.30 -.09 .09 .14

Substance Disorders

.04 .60** .22 .42*

Crime-Violence .47** .48** .45** .66**

Total Disorders .47** .39* .36* .57**

n = 34

Mental Health Composite

Overall, the Mental Health COD screening composite works well, correlating strongly with ASI and GAIN SS measures of mental health problems

AOD Use Composite

The Alcohol/Drug Use COD screening composite relates well to the GAIN SS measure of substance disorder severity but not with the ASI alcohol and drug problems measures

Trauma/DV Composite

As was the case for the individual trauma/domestic violence screening items, the Trauma/Domestic Violence COD screening composite related moderately to the ASI mental health measures and strongly with the GAIN SS crime/violence measure

Total COD Composite

The Total COD screening composite correlated with ASI measures of psychiatric problems and GAIN SS measures of mental health, substance disorders, crime/violence, and total disorders

It appears this measure shows promise for screening for co-occurring disorders

Pilot Study Limitation

Because the instructions specifically indicated the longer screening measures (i.e., ASI, GAIN SS) were only to be administered if one or more answer to the nine COD screening items was endorsed, there is a restricted range of responses in the data available to “predict” scores on the longer (more established) criterion measures

By design, it was not possible to examine whether negative screening data (i.e., cases where all nine items are answered “no”) predicts the absence of problems as measured by the ASI and/or GAIN SS

These data do illustrate the degree to which persons screened as having a possible substance abuse, mental health, and/or trauma issue are likely to have treatment needs as measured by the ASI and GAIN SS measures

That is, among persons already identified as having screened “positive” for one or more of these issues, endorsement of COD screening items and composites is related to the severity of substance abuse and mental health problems