Integrated Dual Disorder Treatment
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1 Integrated Dual Disorder Treatment In a (Dutch) rapid changing environment Strasbourg May 2010 Bas van der Hoorn b.van.der.hoorn@palier.nl
2 Who s talking? Psychiatrist Head of dual diagnosis treatment facility The Hague Founding member LEDD Editor (IDDT) (National Center of Expertise in DD)
3 The Hague Strasbourg
4 Content Introduction The (Dutch) IDDT model The changing environment Current innovations: ROCKSAN trial Money for Medication (M4M) Online sources
5 ParnassiaBavo Group 8000 employees > 0,5 billion euro turnover > 180 locations > patients 90% outpatient large peripheral institute (Not academic) 9 professors Specialized mental care programs
6 The DD treatment program Inpatient care: Closed facility (n =19) Open facility (resocialisation, n = 7) Living arrangement (n = 7) Outpatient care (n=180) Day treatment (n=45) Policlinic (n=120)
7 Psychiatric disorders, not substance related Schizophrenia, other psychotic disorders: 70% Personality disorders: 15% Mood disorders: 10% Other: 5%
8 Others Methadon Substance use Cocaine Cannabis Heroine Alcohol % Substance use disorder (DSM-IV)
9 Dual disorders = double trouble! Relapse of mental illness Treatment problems and hospitalization Violence, victimization, and suicidal behaviour Homelessness Medical problems, HIV & Hepatitis risk behaviours and infection Family problems Increase service use and cost
10 Integrated treatment Ten studies show integrated treatment is more effective than traditional separate treatment Drake, Mueser et al Review
11 Dutch IDDT model Brunette, Drake et al, SAMHSA, VS
12 Principles of integrated treatment Integration of mental health and substance abuse treatment: Same team, dually trained Same location of services Both disorders treated at the same time Stage-wise treatment Different services are effective at different stages of treatment Motivational interviewing / Group therapy
13 Permanent exit Stages of change (in behaviour) Prochaska en Diclemente 1984 Maintain Relapse Act Precontemplation Start Decide Contemplation Temporary exit
14 IDDT: Integrated Dual Diagnosis Treatment (T) Treatment characteristics (G) General Organizational Index
15 IDDT Treatment characteristics 1a : Multidisciplinairy, cross-trained team 1b : Integrated Substance abuse specialist 2 : Stage wise interventions 3 : Access comprehensive DD services 4 : Time unlimited services 5 : Outreaching 6 : Motivational interventions 7 : Substance abuse counselling 8 : Group DD treatment 9 : Family psycho education on DD 10 : Self help groups 11 : Pharmacological treatment 12 : Interventions to promote health 13 : Treatment non-responders (Mueser, 2003)
16 IDDT General Organizational Index 1 : Program philosophy 2 : Client identification 3 : Penetration 4 : Assessment 5 : Individualized treatment plan 6 : Individual treatment 7 : Training 8 : Supervision 9 : Process monitoring 10 : Outcome monitoring 11 : Quality assurance 12 : Client choice
17 Mean fidelity scores 4,5 4 3,5 3 2,5 2 1,5 1 Drenthe Europoort Eindhoven Veldhoven Delft 0,5 0 meting meting meting12-06
18 Cost-effectiveness? Dual diagnosis program Specialized care Justice dept. Addiction care Gen. Mental health General practioner Patients
19
20 Changing environment More severely ill DD population: involuntary treatment housing problems more aggression Social values regarding treatment and general safety Reduce criminal behaviour by treatment
21 Financing health Different health finance system: > Rewarding productivity > Diagnostic treatment combinations (Fixed prices, combinations) > Stimulating strategic thinking and market forces > More overall control
22 Financing (psych) health To gain control over expending costs: > Health care production limit > 3 sponsors (Health Assurance comp., Justice, local gov.) > Leading to: More bureaucracy Inflexibility More risks for health institutions Institutions favor low risk & high benefit care! Merging companies to gain power.
23 Where does this leave the DD population? INNOVATION: Money for medication ROCKSAN Center of DD expertise
24 MONEY FOR MEDICATION? Charlotte Audier
25 . MONEY FOR MEDICATION Money for medication (M4M) is a randomized controlled study on the effectiveness of financial incentives to improve medication adherence in patients with a psychotic disorder and comorbid substance abuse.
26 Why M4M? Non-adherence antipsychotic medication Interrupted intake reduces effectiveness Non-adherence: inconsistent symptom control, more relapses, and more rehospitalisation The most preventable cause Prior research encouraging Contingency Management
27 Goals Primary goal: Acceptance of their prescribed medication, during and after intervention. Secondary goal: Longest period of uninterrupted depot acceptance, time expired before the depot is taken, the effort initiated by the clinicians to provide the depot, the number of admissions, psychiatric symptoms, social and psychological functioning, substance use, subjective wellbeing (quality of life) and subjective wellbeing under neuroleptics.
28 INTERVENTION Intervention group (M4M): Patients assigned to the intervention group will receive treatment as usual, plus a financial incentive for each time they accept their prescribed depot of antipsychotic medication. (max 30 euro/month) Control group (TAU): Patients assigned to the control group will receive treatment as usual only (including the regular encouragement to take their prescribed depot medication). Intervention 12 months, follow up 6 months.
29 Randomized Olanzapine Clozapine Key study Schizophrenia Addiction Netherlands [ROCKSAN] Lieuwe de Haan, Albertine Scheltema Beduin, AMC
30 Why ROCKSAN? Lifetime prevalence of SUD schizophrenia 50%. Some indications that clozapine and perhaps other atypical antipsychotic medications have a favourable effect on SUD. These possible benefits should be weighed against the risk of adverse effects.
31 Goals Primary Is there a difference in effectiveness and costs of clozapine treatment compared to olanzapine treatment in the reduction of substance use. Secondary Are there differences in psychopathology, adverse effects, compliance, drop out rate, psychosocial functioning and quality of life, in these patients?
32 Center of expertise DD
33
34 An independent selection of high quality links by colleagues
35 Thank you for your attention Bas van der Hoorn
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