For many years, those who treat substance use disorders (SUDs) and mental health issues have occupied separate realms. Addiction treatment specialists have been reluctant to treat problems like depression and attention deficit hyperactivity disorder (ADHD), while mental health professionals have shied away from addressing SUDs. The result: individuals with co-occurring addiction and mental health disorders have struggled to find psychiatrists willing to address their substance use, or addiction specialists willing to take on their mental health issues.
Why not treat the two as co-occurring conditions and deliver integrated care? The numbers say it would be a wise decision, maintains Dr. Paula Riggs, a professor of psychiatry with the University of Colorado School of Medicine. Riggs said most kids with adolescent-onset SUD have at least one other co-occurring mental health disorder.
“Most patients who walk through my door have both,” Riggs said. “Co-occurrence of SUDs and other mental health disorders are the rule rather than the exception.”
But Riggs said few psychiatrists feel they have adequate training to treat SUDs, the result of a treatment system that “grew up all wrong,” segregating mental health and addiction treatment and funding them separately. Yet the research of Riggs and many others over more than two decades concludes that individuals with co-occurring disorders have poorer outcomes unless they receive integrated care.
“I saw that if a patient’s depression didn’t remit, nothing happened with their SUD,” she said. Conversely, when a patient’s depression remitted, his or her drug use tended also to decrease. It’s a conclusion supported by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), which notes that “With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes.”
Rates of remission over the 16 weeks of Encompass treatment are as follows:
•Depression: 44 percent
•Anxiety disorders: 50 percent
•ADHD: 57 percent
Riggs put that notion to the test by creating Encompass, a 16-week program aimed at treating adolescents and young adults with co-occurring SUDs and mental health issues. It’s been implemented at a number of sites and was put in place early this year at the Outpatient Psychiatric Practice at UCHealth University of Colorado Hospital. It’s also employed by therapists at Children’s Hospital Colorado on the University of Colorado Anschutz Medical Campus.
The most recent data available show that the Encompass program has produced outcomes for both SUDs and psychiatric diagnoses that are comparable to or better than treatment strategies that address one or the other but not both.
The foundations of Encompass are integrated care, including comprehensive diagnostic evaluations for both SUDs and co-occurring psychiatric disorders; cognitive behavioral therapy (CBT) to help patients discover and address the roots of their conditions; motivational interviewing by therapists to elicit and encourage patients to identify intrinsic reasons they might have to change their behaviors; positive reinforcement for meeting goals, like decreasing drug use or improving relations with family members; and encouragement for patients to find “pro-social” activities and peer relationships that don’t involve using drugs.
Encompass began with NIH-funded controlled clinical trials Riggs designed to test the safety and efficacy of medications to treat depression and ADHD in adolescents with SUDs. These studies supported the safety and effectiveness of medications for depression and ADHD in adolescents who were also enrolled in weekly outpatient substance treatment with individual CBT. An unexpected and consistent finding emerged from the studies, Riggs said: CBT may have contributed to reductions in both substance use and symptoms of depression, anxiety, and ADHD.
With these underpinnings, Riggs developed a detailed manual and treatment regimen for providers based on established science and study. Participants complete two days of on-site training with ongoing supervision and feedback from trainers about specific patient cases. They collect and analyze with Riggs data that evaluate outcome measures like changes in drug use and depression.
The approach has proved successful at Riley Children’s Health in Indianapolis, said Dr. Leslie Hulvershorn, associate professor of psychiatry at Indiana University School of Medicine. Hulvershorn began work with Riggs to implement Encompass at Riley in 2011. In June of this year, CU designated Riley as an Encompass training site. Under that arrangement, Riley is collaborating with a mental health center and a juvenile detention center in Indiana, Hulvershorn said.
“Encompass takes a comprehensive approach that is appropriate for an outpatient setting like ours,” said Hulvershorn, who added that her clinic and hospital had had no SUD programming for young patients prior to working with Riggs. “I was impressed by the breadth of it. We have embraced the model fully, found it to be very beneficial and have been able to sustain it.”
As was true in Indiana, Encompass could filll a treatment space that has been vacant too long, said Gary Kushner, executive director of the Center for Dependency, Addiction and Rehabilitation (CeDAR) at UCH, which is helping to fund Encompass. Kushner said community leaders have increasingly asked what CeDAR is doing to address a “huge gap” in available care for adolescents dealing with SUDs. In addition, therapists in the Outpatient Psychiatric Practice have been “peppered” with questions about co-occurring issues, like SUDs, in treating their patients.
“Encompass was a logical outgrowth of these questions,” Kushner said. “We asked ourselves, ‘Why are we not doing this?’”
Kushner also noted that Encompass is flexible and requires little in the way of bricks and mortar – only the commitment of patients and therapists to meet weekly to focus on building trust and being open to exploring new possibilities for improving mental health and finding positive alternatives to drugs.
“We can meet kids where they’re at, such as at school or in primary care offices,” Kushner said. “The flexibility is noteworthy.” In fact, Riggs spearheaded an Encompass pilot at Adams City High School in Commerce City in 2014. Hulvershorn noted that Riley Children’s Health offers Encompass sessions to kids in five Indiana communities via telehealth links.
Theory to practice
At UCH’s Outpatient Psychiatric Practice, two therapists, Julia Carlson and Andrea Vaughn, supervised by Joel Green, completed the Encompass training. Both said they appreciate the objective foundation of Encompass as well as its focus on helping patients meet their issues on their own terms.
“The Encompass approach is laid out with a beginning, a middle and an end,” Vaughn said. “It’s evidence-based as opposed to what feels right.”
Carlson noted that while Encompass includes 16 modules covering motivation, goal setting, communication, coping with cravings and others, it allows the therapist freedom to work within the structure, depending on the needs of the patient.
“I can follow my own clinical instincts,” Carlson said, “and tweak the modules as I need to. We have the flexibility to do all 16 or go more in depth, spending more than one week on a specific module.”
The program also rejects the notion that kids – or anyone, for that matter – whose lives have been disrupted by drug use need finger-wagging, lecturing or fear-mongering to stop. For one thing, Riggs said, many young people use drugs as a way of regulating the stress of difficult relationships with their families, schools or peers. Social problems like homelessness and lack of access to basic services can further complicate their lives. It’s unreasonable to expect that people in these and other situations will walk into a clinic asking for help, Riggs said. Most of them are in therapy because a school, court or other institution has required that they get it.
“Everybody walks in ambivalent about changing their behavior,” Riggs said.
That means lectures from therapists about the evils of drug use are out. “The more you argue for your own agenda, the more a person’s heels dig in,” as Vaughn put it. Instead, the Encompass approach works toward helping patients recognize the sources of their urges to use drugs and consider how they connect to other aspects of their lives, like family, work and friends. That work is part of CBT, Vaughn said.
“The idea is to get patients to think about the emotions and thoughts that are behind their behaviors and do they match with the goals for their lives,” she said. The therapist and patient can then work together to find ways to manage the triggers that lead to drug use – alleviating boredom, avoiding tense situations with others, meeting at certain times of the day with other friends who use and so on.
Encompass also uses positive reinforcement as a tool to help change behavior. The approach, known as “contingency management,” aims to “reinforce or reward abstinence and treatment compliance and increase frequency of engagement in drug-free pro-social activities,” Riggs said.
It’s a commonsense idea that has empirical support for its effectiveness, Riggs said. “The response to a reward is a principle of behavior reinforcement that is valid across species. It helps to increase the frequency of the behaviors we want. Changing habitual or addictive behavior is hard, but providing rewards for targeted behaviors is a powerful motivator.”
However straightforward the principles of Encompass may be, they are hardly a guarantee of stopping drug use. The complex issues that contribute to it are evident in the life of Marcus (not his real name), a 16-year-old from the Denver area who was about halfway through the Encompass program when he spoke about his situation in late June.
His therapist at UCH’s Outpatient Psychiatric Practice referred Marcus to Encompass to treat his chronic marijuana use and major depressive and post-traumatic stress disorders. After a series of suspensions for absences and attending class while under the influence, his southeast Aurora high school expelled him near the end of the just-completed school year.
Marcus freely admits to smoking marijuana regularly and says he understands the reasons for his expulsion and his parents’ displeasure and worry over his drug use. He says he smoked for the first time in eighth grade, but didn’t like it. In ninth grade, however, he began smoking habitually, saying, “It got me away from some things.”
Those factors included mental health issues his older sister faced that resulted in her attempting suicide. She was hospitalized on several occasions. “We were really close and I didn’t know how to cope with that mentally,” Marcus said. “It was on my mind almost every day. I felt like I was alone and by myself. I’d get high and not be thinking about it.”
Marcus also witnessed a cousin who had lived with him and his family for years taken from the home by the cousin’s father. About a year ago, Marcus’s home burned down, killing his three dogs, who were trapped inside. His family lived in a series of temporary lodgings while waiting to move back to their home.
He doesn’t use these travails as an excuse for using drugs. In fact, he admits that when his school suspended him for the first time in ninth grade, he “didn’t understand what was so bad about it. I never thought it was an issue.”
His environment might have something to do with that. Asked about the time he has to spend finding weed and how that might cut into other activities, he gently scoffs. “It’s high school in Colorado. Everyone knows how to get it.”
Drug classes his high school required him to take as part of his suspensions had no effect on his behavior, he added. “They gave us information on the stages of addiction,” he said. “They never taught me anything,” he said.
He works with Vaughn on his Encompass therapy, aiming to improve his relationship with his dad, who is an Army veteran, manage his drug use, and find positive social alternatives to smoking. He said he and Vaughn discussed volunteering, but for now he’s chosen to look for a job at fast-food restaurants or shoe stores that dot the area where he lives.
Vaughn also showed him hard data that illuminates the heightened physical and cognitive risks of heavy smoking – and that his chronic drug use is not in step with the vast majority of his high school peers. “I understand the effects that marijuana has on my brain and my lungs,” he said. “That’s science.” He said he also has a better grasp of the fears his parents have – including physical harm – if he makes no changes in his behavior.
“Andrea has helped me find ways to not necessarily stop smoking but to cut back and has given me tips on how to not want it as much,” Marcus said, adding that he’s now stopped smoking at night completely. “She gave me a place to talk to somebody who doesn’t just want me to stop smoking.”
For her part, Vaughn said that Encompass can help young adults like Marcus examine, often for the first time, why they are using drugs and increase their curiosity about the triggers, like loneliness or boredom, that lead them to use.
“For kids who are wrestling with distressing emotions or difficult life circumstances, we try to show them other ways to cope, even if weed or other drugs are not involved,” Vaughn said.
Most importantly, she added, Encompass uses CBT, contingency management and other techniques to teach patients “to be their own therapist by learning to challenge their distorted thoughts and to regulate their emotions. That can be viable if their parents aren’t supportive. An intrinsic approach is more sustainable, which is why Encompass helps clients find their own motivations for not using drugs.”
Hulvershorn, who has seven years of work with Encompass to draw on, agrees. “One of the learning points for us has been that it doesn’t create behavioral change in kids to yell at them and tell them that drugs aren’t good,” she said. “It turns out that’s not helpful.”
On the other hand, Hulvershorn added, she’s seen kids in Indiana, many of them severely impaired by drug use and mental health issues, respond very well to the Encompass model, particularly when it is bolstered with family therapy.
“I wish we could get every kid in the state connected to it because it is focused on getting them engaged in outside activities and feeling good about themselves and addressing their mental health issues. It’s the total package.”
It’s early days for Encompass at UCH, but CeDAR director Kushner said there is ample reason to support it as an alternative to detentions, suspensions, expulsions and incarcerations.
“We decided to invest in Encompass because the need is so great,” he said. “There is a lack of programming in the community for adolescents with substance use disorders. I think that most people would agree that reaching out to kids in their formative years and encouraging pro-social activities is a more effective way to go.”
Signs of success
Paula Riggs, who created Encompass, says the program has produced positive outcomes for patients treated for co-occurring substance use disorders (SUDs) and mental health issues.
About 40 percent of Encompass patients with a SUD achieve at least one month of abstinence by the end of treatment, Riggs said in an email. “Even those who don’t achieve abstinence during treatment reduce the amount they use by about 50 percent.”
Riggs said these numbers are comparable to or better than published outcomes for SUD treatments like cognitive behavioral therapy, family-based interventions and others – none of which treat co-occurring psychiatric conditions, as Encompass does. In addition, she noted that patients treated by Encompass meet diagnostic criteria for 2.1 SUDs (including marijuana, alcohol and opioids, but not tobacco) and 2.3 co-occurring psychiatric disorders, including major depression, anxiety issues and ADHD.
Similarly, Riggs said, Encompass has achieved reductions in the severity of patients’ psychiatric symptoms comparable to or better than patients treated for depression, anxiety or ADHD – but without a SUD.