WHY FOCUS ON WHAT IS YOUR PROGRAM’S CO-OCCURRING … · CO-OCCURRING DISORDERS? 1. Substance use...

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WHAT IS YOUR PROGRAM’S CAPABILITY WITH CO-OCCURRING

DISORDERS?: An introduction to the DDCAT

(& DDCMHT)

2009 MARRCH Conference

22 October 2009

NIDA, SAMHSA & THE ROBERT WOOD JOHNSON FOUNDATION SUBSTANCE ABUSE POLICY RESEARCH PROGRAM

WHY FOCUS ON CO-OCCURRING DISORDERS?

1. Substance use disorders are common in people with mental health disorders

2. Mental health disorders are common in people with substance use disorders

3. Co-occurring disorders lead to worse outcomes and higher costs than single disorders

4. Evidence-based models exist and can be implemented 5. Providers and consumers want a better system and

services 6. Few (<10%) people get the treatments they need.

COMORBIDITY OF SUBSTANCE USE AND SPECIFIC AXIS I PSYCHIATRIC DISORDERS

Any Substance

Alcohol Diagnosis

Other Drug Diagnosis

Schizophrenia 47% 4.6 33.7% 3.3 27.5% 6.2

ASPD 83.6% 29.6 73.6% 21.0 42% 13.4

Anxiety disorders 23.7% 1.7 17.9% 1.5 11.9% 2.5

Phobia 22.9% 1.6 17.3% 1.4 11.2% 2.2

Panic disorder 35.8% 2.9 28.7% 2.6 16.7% 3.2

OCD 32.8% 2.5 24% 2.1 18.4% 3.7

Bipolar Disorder 60.7% 7.9 46.2% 5.6 40.7% 11.1

Major depression 27.2% 1.9 16.5%* 1.3 18% 3.8

  Cocaine 76.1% (11.3)

  Barbiturates 74.7% (10.8)

 Hallucinogens 69.2% (8.0)

 Opiates 65.2% (6.7)

  Alcohol 36.6% (2.3)

LIFETIME RISK OF ANY MENTAL HEALTH DISORDER BY SUBSTANCE USE DISORDER

WHY DO WE NEED TO MEASURE CO-OCCURRING CAPABILITY?

1. Generic terms “integrated” or “enhanced” are “feel good” rhetoric but lack specificity. 2. Systems and providers seek guidance, objective criteria and benchmarks for providing

the best possible services. 3. Patients and families should be informed about the range of services, to express preferences and make educated treatment decisions.

4. Change efforts can be focused and outcomes of these initiatives assessed.

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SPECIFIC AIMS

1.  To develop an index that can objectively determine the dual diagnosis capability of addiction treatment services.

3.   To develop practical operational benchmarks on key dimensions, and to determine if changes can be made & measured.

3. To identify change strategies that are particularly effective for enhancing the dual diagnosis capability of addiction treatment services

DDCAT INDEX: DEVELOPMENT

•  Practical program level policy, practice and workforce benchmarks: Based on scientific literature and expert consensus

•  Observational methodology: Interviews; Document review; Social, environmental & cultural ethnography (vs. self-report)

•  Iterative process of measure refinement: Field testing and psychometric analyses

•  Materials: Index, manual, toolkit & Excel workbook for scoring and graphic profiles

IS THERE A CONCEPTUAL MODEL THAT COULD GUIDE RESEARCH AND PRACTICE

FOR ADDICTION TREATMENT?

•  The American Society of Addiction Medicine (ASAM) Patient Placement Criteria Second Edition Revised (PPC-2R) outlined the framework for a model

•  The ASAM-PPC-2R is designed for addiction treatment services

•  The ASAM-PPC-2R patient placement criteria have been widely adopted in public and private community addiction treatment

ASAM TAXONOMY OF DUAL DIAGNOSIS SERVICES

(ASAM, 2001)

•  ADDICTION ONLY SERVICES (AOS)

•  DUAL DIAGNOSIS CAPABLE (DDC)

•  DUAL DIAGNOSIS ENHANCED (DDE)

ADDICTION ONLY SERVICES (AOS)

Programs that either by choice or for lack of

resources, cannot accommodate patients

who have psychiatric illnesses that require

ongoing treatment, however stable the

illness and however well-functioning the

patient.

DUAL DIAGNOSIS CAPABLE (DDC)

Programs that have a primary focus on the

treatment of substance-related disorders, but are

also capable of treating patients who have

relatively stable diagnostic or sub-diagnostic co-

occurring mental health problems related to an

emotional, behavioral or cognitive disorder.

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DUAL DIAGNOSIS ENHANCED (DDE)

Programs that are designed to treat patients

who have more unstable or disabling co-

occurring mental disorders in addition to their

substance-related disorders.

DETERMINING DUAL DIAGNOSIS CAPABILITY BY ADDICTION TREATMENT

PROVIDER SURVEY

Addiction Only Services (AOS) 97 (23.0%)

Dual Diagnosis Capable (DDC) 275 (65.3%)

Dual Diagnosis Enhanced (DDE) 49 (11.6%)

(n=453)(McGovern et al, 2006b)

ASAM DUAL-DIAGNOSIS TAXONOMY SURVEY IS USEFUL BUT

MAY HAVE ACCURACY PROBLEMS

•  92.9% of sample responded to item (421/453)

•  No differences in categories by professional role: Agency Directors vs. Clinical Supervisors vs. Clinicians

•  Modest agreement among staff within programs: 47.3% •  Survey method is rapid and economical:

Provides initial data (screening) •  Survey method may have bias and error (ambiguity)

THE NEED FOR A MORE OBJECTIVE ASSESSMENT OF

ADDICTION TREATMENT SERVICES’ DUAL DIAGNOSIS CAPABILITY

•  ASAM offers the road map, but no operational definitions for categories or services

•  Fidelity: Adherence to an evidence-based practice or model

•  Fidelity scales: Objective ratings of adherence in mental health services research

•  Can we apply fidelity scale methods to estimate dual diagnosis capability?

APPLYING THE FIDELITY SCALE METHODOLOGY FOR A

MORE OBJECTIVE ASSESSMENT OF DUAL DIAGNOSIS CAPABILITY

•  Site visit (yields data beyond self-report)

•  Multiple sources: •  1) Documents and materials •  2) Ethnographic observation

3) Interviews with staff and patients •  Unit of analysis: Program

•  “Triangulation” of data

DUAL DIAGNOSIS CAPABILITY IN ADDICTION TREATMENT (DDCAT) INDEX:

DEVELOPMENT & FEASIBILITY

•  Index (instrument) construction •  Feedback from experts in dual-diagnosis

treatment and research, state agency administrators, addiction treatment providers, and fidelity measure experts

•  Field testing the DDCAT index 1.0 (2003) •  Site visits in programs •  Found to be doable, useful information for

providers and psychometrically sound

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DDCAT PSYCHOMETIC PROPERTIES

Reliability •  Median alpha = .81 (Range .73 to .93) •  Inter-rater reliability (MO): .76 •  Inter-rater reliability (LA): .84 •  Kappa (MO) = .67 (median) •  Sensitivity to change (CT): p < .05 @ 9 months

Validity •  Correlation with IDDT Fidelity Scale: Median = .69 (.38 to .82) •  Relationship with psychiatric severity levels at admission:

Increasing access for persons with co-occurring disorder from AOS to DDC to DDE level programs (p<.001)

(Gotham et al, 2004; McGovern et al, 2006, 2007; Brown & Comaty, 2007)

DUAL DIAGNOSIS CAPABILITY IN MENTAL HEALTH TREATMENT (DDCMHT) INDEX

•  Designed by Drs. Heather Gotham, Jessica Brown & Joseph Comaty as companion to DDCAT but for use in mental health programs.

•  Common metric and method: 35 items, 7 dimensions, programs categorized as Mental Health Only Services (MHOS), DDC or DDE

•  More likely presentation of QIII patients in mental health system (than addiction treatment system)

•  Makes comparisons between systems possible

DUAL DIAGNOSIS CAPABILITY IN MENTAL HEALTH TREATMENT (DDCMHT) INDEX

•  Focus on substance use capable services within a mental health program

•  Compares with the Integrated Dual Disorder Treatment model (IDDT) and fidelity scale (which focus on specialized team within a program/agency)

•  Less data are presently available •  Being used in statewide change initiatives in

Louisiana, Missouri, New York and Vermont

DDCAT & DDCMHT (3.2): 7 DIMENSIONS & CONTENT OF 35 ITEMS

Dimension Content of items

I Program Structure Program mission, structure and financing, format for delivery of mental health or addiction services.

II Program Milieu Physical, social and cultural environment for persons with psychiatric or substance use problems.

III Clinical Process: Assessment

Processes for access and entry into services, screening, assessment & diagnosis.

IV Clinical Process: Treatment

Processes for treatment including pharmacological and psychosocial evidence-based formats.

V Continuity of Care Discharge and continuity for both substance use and psychiatric services, peer recovery supports.

VI Staffing Presence, role and integration of staff with mental health and/or addiction expertise, supervision process

VII Training Proportion of staff trained and program’s training strategy for co-occurring disorder issues.

DDCAT/DDCMHT INDEX RATINGS

1 - Addiction Only Services(AOS) or Mental Health Only Services (MHOS) 2 -

3 - Dual Diagnosis Capable (DDC) 4 - 5 - Dual Diagnosis Enhanced (DDE)

DDCAT/DDCMHT DATA COLLECTION: SOURCE, DIMENSION & TIME ALLOCATION

•  Meet with agency leadership (I, VI, VII)(30’)

•  Tour of program (II, III)(30’) •  Meet with clinicians and other staff (III-VI)(30’) •  Meet with patients (II, V)(30’)

•  Observe clinical interaction or team meetings when possible (II-V)(30’)

•  Review documents including medical records, brochures, program schedules, any patient/family handouts, policy & procedure manual (I-V)(60’)

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I.  PROGRAM STRUCTURE

I.A. Primary treatment focus as stated in mission statement

DDCAT: Is the stated focus addiction only, primarily addiction (with an acknowledgement of psychiatric problems) or dual diagnosis?

DDCMHT:

Is the stated focus mental health only, primarily mental health (with acknowledgement of substance use problems) or dual diagnosis?

I. PROGRAM STRUCTURE

I.B. Organizational certification and licensure

What does licensure/certification permit? Are there impediments to providing certain types

of services?

Are these impediments real?

I.  PROGRAM STRUCTURE

I.C. Co-ordination and collaboration with mental health or addiction services

DDCAT: How & where are psychiatric services provided? Through relationships or integrated? Are these relationships formalized & documented?

DDCMHT:

How & where are addiction treatments provided? Through relationships or integrated? Are these relationships formalized & documented?

I. PROGRAM STRUCTURE

I.D. Financial incentives.

How do billing structures limit or incentivize services for persons with addiction and/or

psychiatric disorders?

II. PROGRAM MILIEU

II.A. Routine expectation of and welcome to treatment for both

disorders.

What patients are expected and welcomed? How is this reflected in agency documents?

II. PROGRAM MILIEU

II.B. Display and distribution of literature and patient educational materials.

What kind of information is posted on walls, on display in waiting areas, and included in patient

& family handouts and printed materials?

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III. CLINICAL PROCESS: ASSESSMENT

III.A. Routine screening methods for psychiatric or substance use symptoms

DDCAT:

Are there routines or systems to screen for psychiatric problems? Are screening instruments used?

Are procedures systematic?

DDCMHT: Are there routines or systems to screen for substance use problems? Are screening instruments used? Are toxicological data gathered?


III.B. Routine assessment if screened positive for

psychiatric symptoms

If a patient screens positive, are more detailed assessments triggered?

Are these assessments formalized & integrated?


III.C. Psychiatric and substance use diagnoses made and

documented

If assessments are conducted, are psychiatric diagnoses made in addition to the substance use disorder?

Are substance use disorder diagnoses made in addition to the psychiatric disorder?


III.D. Psychiatric and substance use history reflected in

medical record.

Are the chronologies and treatment course of disorders gathered (and recorded)?


III.E. Program acceptance based on symptom acuity: Low, moderate, high

DDCAT:

What happens to patients who call or present for services with stable psychiatric symptoms? Or, unstable ones?

DDCMHT: What happens to patients who call or present for services with substance use in remission? Or, active substance use or intoxication? of addiction treatment?


III.F. Program acceptance based on severity and persistence of disability:

Low, moderate, high

DDCAT:

What happens to patients with histories or records of severe and persistent psychiatric problems? Severe mental illness?

DDCMHT: What happens to patients with histories or records of severe substance dependence, and repeated patterns of compulsive use?

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III.G. Stage-wise assessment

Is stage of motivation assessed and documented? Is motivation to change and to use treatment

assessed for both substance use and mental health problems?

IV. CLINICAL PROCESS: TREATMENT

IV.A. Treatment plans

Do treatment plans show an equivalent and integrated focus on both substance use and

psychiatric disorders, or do they primarily focus on substance use (DDCAT) or

psychiatric (DDCMHT) issues only?


IV.B. Assess and monitor interactive courses of both disorders.

Are changes and/or progress with status and symptoms of both psychiatric

and substance use disorders followed

(and noted)?


IV.C. Procedures for psychiatric or substance use emergencies and

crisis management

Are there definite protocols for psychiatric or substance use crises

and/or those at high-risk?


IV.D. Stage-wise treatment

Is stage of motivation assessed on an ongoing basis? Can treatment be revised based upon changes in

motivation? Are assessments and treatments focused on differential

stages in patient motivation to change (and get help with) both mental health and

substance use problems?


IV.E. Policies and procedures for medication evaluation,

management, monitoring and compliance

Are medications acceptable? Are certain medications unacceptable? Are medications routine & integrated?

Are psychiatric and/or addiction medications available?

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IV.F. Specialized interventions with mental health (DDCAT) or addiction

(DDCMHT) content

DDCAT: Are therapies available that focus on addiction only, generic psychological concerns, or focused on specific psychiatric disorders

(in addition to substance use treatments)?

DDCMHT: Are therapies available that focus on mental health only, generic lifestyle or behavioral concerns or on specific substance use disorders?


IV.G. Education about co-occurring psychiatric disorder and or substance use and

integrated treatment

Is information available on how substance use impacts a psychiatric disorder and vice versa? Is

information available about how co-occurring disorders affect treatment and recovery?


IV.H. Family education and support

Are family members provided information on how substance use impacts a

psychiatric disorder and vice versa? What kind of support is available for

families on these issues?


IV.I. Specialized interventions to facilitate use of peer support

groups in planning or during treatment

In facilitating the connection to peer recovery support groups,

how are psychiatric disorders considered? How are substance use disorders considered?

Are specialized introductions available?


IV.J. Availability of peer recovery supports for patients with CODs

Are peer supports and role models available for patients with co-occurring substance use and

psychiatric disorders? If so, are they on or off site, integrated with

programming?

V. CONTINUITY OF CARE

V.A. Co-occurring disorder addressed in discharge

planning process

Is recovery from both psychiatric and substance use disorders

considered when developing a discharge plan?

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V.B. Capacity to maintain treatment continuity

How is treatment terminated or continued?

Is this equivalent for both addiction and psychiatric disorders?


V.C. Focus on ongoing recovery issues for both disorders

Are the disorders seen as acute or chronic, short-term or long-term, primary or secondary?

How is recovery envisioned and planned?


V.D. Facilitation of peer support groups for COD is documented and a focus in discharge planning, and

connections are insured to community peer recovery support groups.

Is the potential increased peer support group linkage difficulty for the person with a psychiatric disorder

anticipated and planned for? How is it dealt with?


V.E. Sufficient supply and compliance plan for

medications is documented

How is the need for continued prescribing and medication supply dealt with?

Are both psychiatric and addiction medications made available?

VI. STAFFING

VI.A. Psychiatrist or other physician or prescriber of psychotropic (DDCAT) or addiction (DDCMHT) medications

What is the relationship with a psychiatrist, physician, or nurse practitioner

(or other licensed prescribers)?

VI. STAFFING

VI.B. On site clinical staff members with mental health (DDCAT) or

drug and alcohol (DDCMHT) licensure or competency

Are any staff licensed to provide mental health services?

Addiction services? Co-occurring services?

What percentage of all staff?

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VI. STAFFING

VI.C. Access to mental health (DDCAT) or addiction (DDCMHT)

supervision or consultation

What is the arrangement for mental health or addiction treatment supervision and/or consultation for

non-licensed staff?

VI. STAFFING

VI.D. Case review, staffing or utilization review procedures emphasize and support COD

treatment.

Is there a protocol to review the progress or process of treatments for psychiatric and substance use disorders?

VI. STAFFING

VI.E. Peer/Alumni supports are available with co-occurring

disorders

Are role models available for persons with co-occurring addiction and psychiatric disorders?

VII. TRAINING

VII.A. Direct care staff members have basic training in prevalence, common signs & symptoms, screening and assessment for

psychiatric symptoms and disorders (DDCAT) and substance use symptoms

and disorders (DDCMHT).

Who has basic training in screening & assessment?

Is training documented?

VII. TRAINING

VII.B. Direct care staff are cross-trained in mental health and substance use disorders,

including pharmacotherapies & have specialized training in treatment of persons with COD.

Who is trained?

Is staff training guided and monitored? What percentage of all staff?

DDCAT/DDCMHT EXCEL WORKBOOK: SUMS & AVERAGES SCORES,

GRAPHIC PROFILE

•  Complete “face” page of Excel workbook •  Transfer scores from rating scale onto Excel

workbook scoring page (no need to calculate dimension averages)

•  Review dimension averages and program categorization: AOS/MHOS, DDC or DDE

•  Review DDCAT/DDCMHT profile line graph

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DDCAT/DDCMHT INDEX: SUMMARY & FEEDBACK

•  Parallel process to clinical interaction: In both respect and tone MI/MET like

•  Assessing organizational stage/targets of change •  Affirmation of strengths •  Elicit concerns and/or areas of potential growth and

perceived barriers •  Discuss potential strategies for enhancement •  Format: Verbal and/or written (Integrative summary

letter and graphic profile)

AOS/MHOS

DDC

DDE

DDCAT/DDCMHT PROFILE: PRACTICAL GUIDANCE FOR PROVIDERS

DDCAT/DDCMHT INDEX: PROVIDER EXPERIENCES

•  Very positive •  Appreciate concrete suggestions about potential

enhancement of services •  Requests for specific information: training,

screening measures, evidence-based treatments •  Verification of real financial constraints •  Curiosity about other programs, states •  Interest in measuring change over time •  Value use of graphic DDCAT/DDCMHT profiles

DDCAT/DDCMHT INDEXES: SELF-ADMINISTERED FORMATS

•  Several efforts to utilize DDCAT index as self-administered measure: Economic, practical, less intensive resource issue

•  Balancing accuracy with practicality •  Projects underway in: MA, NJ, Australia, IN •  Comparison data available only for the

Australian sample, and previous research in CT

DDCAT: SELF VS. INDEPENDENT RATINGS (n=14 agencies in Australia)

USING THE DDCAT/DDCMHT TO GUIDE AND MEASURE CHANGE

•  Use of the DDCAT/DDCMHT as assessment method at baseline and as a measure of change over time.

•  Formal implementation and change plan development

•  Co-Occurring State Incentive Grant (COSIG) initiatives

•  Private non-profit agencies: CQI process •  Use within NIATx change process

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AOS

DDC

DDE

DDCAT PROFILE: An Outpatient Program in Baton Rouge

DDCAT/DDCMHT PROFILE CASE STUDY: UNDERACHIEVING PROGRAM

DDCAT/DDCMHT PROFILE CASE STUDY: OVERACHIEVING PROGRAM

DDCAT PROFILES: 3 programs within a single agency

DDE

DDC

AOS

CLINICAL AND PROGRAMMATIC STAGES OF CHANGE:

PARALLEL PROCESSES

CLINICAL CHANGE PROCESS

PROGRAM CHANGE PROCESS

Screening & Assessment Screening & Assessment

Treatment or

Recovery Plan

Implementation or Change Plan

Outcomes Outcomes

Relapse Prevention Monitoring and Sustainability

DEVELOPING A PROGRAM IMPLEMENTATION OR

CHANGE PLAN USING DDCAT/DDCMHT DATA

1.  Identify the DDCAT/DDCMHT dimension (Goal)

2.   Identify the DDCAT/DDCMHT item(s) (Objectives) 3.   Identify the “Intervention” 4.   Identify the responsible persons

5.   Identify the Target Date 6.   Identify Measurable Outcomes

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DRAFT IMPLEMENTATION PLAN FOR THE BATON ROUGE PROGRAM

D GOAL OBJECTIVE

II Program

Milieu

Make milieu more welcoming; Provide handouts to patients, families; Change some items on walls.

IV Clinical:

Treatment

Develop educational group for patients on common psychiatric disorders, include segment in family night.

VII Training Get all existing staff basic training in COD issues; Add to new staff in-service orientation.

DDE

DDC

AOS

DDCAT PROFILES OVER TIME: DEPICTING PROGRAM CHANGE

STATEWIDE DDCAT/DDCMHT CHANGE

RWJ FUNDED MULTI-STATE LEARNING COLLABORATIVE

•  Purpose: To learn from one another’s experience and efforts to improve services for persons with co-occurring disorders (policy, practice & workforce); Most have in common the use of DDCAT/DDCMHT measures

•  Data sharing agreement; Combined data set (9 states) •  13 “official” member states (+ LA County);

10 active (+LA County) •  One face-to-face meeting (2007); Monthly conference calls

since •  Focus varies: Measure specific issues; successful and

unsuccessful projects; sustainability questions

COLLABORATIVE DATABASE: ADDICTION TREATMENT PROGRAMS (n=170)

Level of Care N (%)

Outpatient 45 (26%)

Intensive Outpatient 46 (27%)

Residential 70 (41%)

Inpatient 1 (1%)

Methadone Maintenance 8 (5%)

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COLLABORATIVE : MENTAL HEALTH TREATMENT PROGRAMS

(n=58)

Level of Care N (%)

Outpatient 53 (91%)

Partial Hospitalization 3 (5%)

Inpatient 2 (4%)

9 STATE BASELINE DDCAT SUMMARY CATEGORIES (n=170)

5 STATE BASELINE DDCMHT SUMMARY CATEGORIES (n=58)

DDCAT/DDCMHT BASELINE PROGRAM CATEGORIES

DDCAT/DDCMHT PROGRAM CATEGORIES: BASELINE AND 9-12 MONTH FOLLOW-UP DDCAT CHANGES BY DIMENSION (n=71)

Baseline Follow-up t-value

Dimensions Mean (sd) Mean (sd)

I. Program Structure 2.66 (1.06) 3.13 (0.95) -5.48***

II. Program Milieu 2.68 (0.56) 3.30 (0.75) -8.99***

III. Assessment 2.78 (0.65) 3.22 (0.65) -9.07***

IV. Treatment 2.35 (0.56) 2.72 (0.57) -7.83***

V. Continuity of care 2.61 (0.79) 2.97 (0.85) -5.63***

VI. Staffing 2.90 (0.82) 3.21 (0.85) -5.31***

VII. Training 2.30 (0.74) 2.78 (0.81) -5.20***

Overall 2.61 (0.61) 3.04 (0.64) -10.98***

***p<.001

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DDCMHT CHANGES BY DIMENSION (n=45)

Baseline Follow-up t-value

Dimensions Mean (sd) Mean (sd)

I. Program Structure 2.73 (1.00) 3.52 (0.98) -5.16***

II. Program Milieu 2.88 (0.85) 3.82 (0.72) -8.56***

III. Assessment 2.78 (0.47) 3.47 (0.47) -8.21***

IV. Treatment 2.12 (0.45) 2.72 (0.50) -9.10***

V. Continuity of care 2.30 (0.78) 2.86 (0.56) -6.24***

VI. Staffing 2.50 (0.64) 3.22 (0.70) -7.70***

VII. Training 2.23 (0.60) 2.96 (0.88) -6.15***

Overall 2.51 (0.55) 3.22 (0.56) -9.17***

***p<.001

NEXT STEPS

•  Consider using the DDCAT or DDCMHT to assess your treatment services

•  Most valid if program is assessed by “independent and objective” person(s)

•  Options: Reciprocate with other programs (Louisiana model), state agency (Minnesota?) or outside consultant

•  Use information to plan, guide and measure change

RESOURCES

•  DDCAT Toolkit http://dms.dartmouth.edu/prc/dual/pdf/ddcat_toolkit.pdf

Operational definitions for all 35 DDCAT benchmarks and specific suggestions, with real examples, of how to move from AOS to DDC or DDC to DDE scores

•  Hazelden CDP Clinical Administrators Guidebook

http://www.hazelden.org/OA_HTML/ibeCCtpItmDspRte.jsp?item=13480&sitex=10020:22372:US

Operational definitions for all of both the DDCAT and DDCMHT items, practical suggestions, examples, and actual tools for quality improvement

Mark McGovern Associate Professor

Department of Psychiatry Department of Community & Family Medicine

Dartmouth Medical School 2 Whipple Place, #202 Lebanon, NH 03766

(603) 381-1160 (603) 448-0129 FAX

[email protected]

http://dms.dartmouth.edu/prc/dual/atsr/ http://www.cooccurring.org/public/index.page

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