Site Study of Dual Diagnosis (MICA) Among Individuals Using MH Services

The gender-specific portion of this study was funded by a B-Start award to Dr. Alexander.

The study was conducted in a random sample of 49 clinical settings in eastern New York State that served adults with severe mental illness diagnoses. Sites were stratified by agency characteristics: ownership (public and private), clinical service (inpatient, ambulatory clinic, case management, social/ vocational rehabilitation), and agency complexity (multiple service provider; single service). In order to enhance the generalizability of the study results, New York City was excluded from the sampling universe.

Data collection was completed in Summer 1997. This had been delayed because of a lawsuit in NYS regarding consents for research participation. Although this particular study did not fall within the purview of the suit, some sites had become reluctant to participate and required additional assurances. At each setting, research staff reviewed random samples of records to yield 2 study samples. The samples are as follows:

Record reviews and interviews were conducted by field staff who was trained in study procedures. Gender, age, ethnicity, psychiatric diagnoses of record and substance use diagnoses as well as the presence of an alcohol or substance use problem or diagnosis recorded in the narrative portion of the chart were recorded.

The interview covered the following broad domains: Alcohol and Substance use problems and history (ASI); housing, family relations, social relations, leisure, safety, finances, health, job, school, mental health service utilization; optimism, coping and advocacy dimensions of empowerment. Additional questions were included about early exposure to risks for alcohol and substance use that have been identified for women without severe mental illness, such as familial substance use and victimization.

Measures of dual diagnoses. Diagnostic and disability criteria for severe mental illness were collected by medical record review in the ongoing study. Substance use problems were identified by record review, rated by treating clinician, and were assessed by the field staff according to ASI criteria relevant for clients with severe mental illness during direct patient interview.

Record review identification. Clients whose records included a current DSM-IV Substance Abuse or Dependence diagnosis, or a notation of a current alcohol or substance use problem were classified as having a current MICA problem. Past diagnoses (in remission) and past problems were also noted as prior problems with a 5 year time frame.

Clinical identification. Clients with severe mental illness who were identified by record review or clinician interview as having a substance use problem during the 6 months prior to the beginning of this inpatient episode, or this outpatient contact were clinically identified as having a current MICA problem.

Research identification. Respondents who reported consequences of using any of the 13 substances queried in the ASI that met criteria for severity rating greater than 2 on the Clinician Rating Scale were identified as having a current MICA problem. Raters used information from the ASI to establish a score on the on the Substance Abuse Rating Scale (Drake, Mueser and Mchugo, 1995) ranged from .62 to .91 for alcohol use problems and from .65 to .85 for drug use problems.

Prevalence rates. Five-year treated prevalence rates of co occurring MICA problems across clinical setting types were over 50%, and reach 70% in inpatient settings. Almost half of women and two thirds of men reported MICA problems in the prior 5 years. In Inpatient settings, current MICA problems were identified in 40% of women and 49% of men. Current rates of MICA problems were 17% for women and 27% for men.

Profiles of substance use. Alcohol, pot, crack/cocaine and sedatives are substances with high rates of use. People with MICA problems are at risk to overdose (especially women) and are at risk for HIV infection by virtue of injection behavior. Both men and women with MICA problems were more likely than their NotMICA counterparts to have been in jail in their lifetimes, and to have been arrested in the prior year. Few study participants reported that they received either mental health or substance abuse services in jail. Individuals with MICA problems, especially women, come from families with histories of substance abuse.

Associated risk factors. Women with MCIA problems were 1.6x as likely to report having been sexually abused as children and 2x as likely to report having experienced emotional abuse as children. Although rates of homelessness and victimization are relatively low in this sample, MICA women were over 4x as likely as their NotMICA counterparts to have been literally homeless and were almost 5x as likely to have lived doubled up in the prior year. MICA men were over 5x as likely as their NotMICA counterparts to have been victims of violent crime and almost 2x as likely to have been victims of non violent crimes in the prior year. Women were more likely to have been victims of either violent or non-violent crimes.

Service utilization. Thirty per cent of those with lifetime MICA problems have never received treatment for their substance use problems, despite the fact that alcohol or drugs are implicated in the use of roughly half of reported inpatient and outpatient psychiatric episodes. There were gender differences in the types of services used recently: MICA women were 4x as likely as NotMICA women to use emergency room services in the prior 3 months. MICA men were as likely as MICA women and 1.5x as likely as NotMICA men to use psychiatric outpatient services. MICA men and women were 1.7x as likely as NotMICA men and women to use psychiatric inpatient services. People with MICA problems relied on self help and outpatient counseling services for help with their alcohol and drug problems.

	American Indian or Alaskan Native	Asian or Pacific Islander	Black, not of Hispanic Origin	Hispanic	White, not of Hispanic Origin	Other or Unknown	TOTAL
Female	1	1	53	13	193	44	305
Male	1	0	74	19	222	47	363
Unknown	0	0	0	0	0	3	3
TOTAL	2	1	127	32	415	94	671

	American Indian or Alaskan Native	Asian or Pacific Islander	Black, not of Hispanic Origin	Hispanic	White, not of Hispanic Origin	Other or Unknown	TOTAL
Female	1	4	42	7	188	18	260
Male	0	3	50	18	202	13	286
Unknown	0	0	0	0	0	0	0
TOTAL	1	7	92	25	390	31	546

Co-occurring disorders have significant effects on the course and severity of severe mental illness. They also place individuals with severe mental illness at risk for other serious health and social consequences including HIV and other sexually transmitted diseases, violent victimization, criminal justice involvement and residential instability. While our findings corroborate that dual diagnoses are more prevalent among men who use mental health services than among women, fully half of the women in this study had a co-occurring alcohol or substance use problem.

Standard profiles of "the MICA client" divert attention from women's alcohol and drug problems and the risks associated with them. The gender specific profiles generated by this study highlight the role of a family history of substance abuse, a history of childhood victimization, current relationship with a substance abuser, and the presence of a diagnosis of borderline personality disorder in the risk of a woman with severe mental illness to have concurrent substance abuse problems. Women with co occurring disorders were also more likely to have had recent residential problems. For men, critical variables include a current relationship with a substance abuser, later onset of severe mental illness, and a family history of alcoholism. For both men and women, MICA problems are associated with having served time in jail.

Policy input: The investigators participated in activities of the NYS Office of Mental Health MICA Work Group, and the 16-county Hudson River Region MICA planning board. The MICA Work group produced a draft policy statement that recommended strategies for collaboration across mental health, alcohol and substance abuse systems, as well as forensic and children's task forces regarding issues of chemical dependency. These included the creation and support of locally planned MICA networks, ongoing cross system training, and MICA targeted funding that promotes programmatic flexibility and increased service availability. From a research perspective, measures of service effectiveness and individual outcomes should be established, and existing programs that target MICA problems should be evaluated. A cross agency committee should be formed to discuss how to disseminate research, to ensure that research and practice are integrated, and to compose a best practices document.

The data collected in this study will be analyzed and reported in a number of publications and presentations.

Alexander M.J. & Muenzenmeier K. (1998). Trauma, addiction and recovery: Addressing public health epidemics among women with severe mental illness, in Levin, B.L., Jennings A. and Blanche A. (Eds.), Women's mental health services: A public health perspective. Beverly Hills, CA: Sage

Alexander M.J. (1998). Women with co-occurring addictive and mental disorders: An emerging profile of vulnerability, in Drake R.E., Mercer-McFadden, C., McHugo, G.F., Mueser, K.T., Rosenberg, S.D., Clark R.E. & Brunette M.F. (eds.) Readings in dual diagnosis. International Association of Psychosocial Rehabilitation Services: Columbia, MD.

Alexander M.J. & Haugland G. (In preparation) Gender specific rates of alcohol and substance use problems among individuals with severe mental illness in treatment.

Alexander MJ and Haugland G (1998). Family support for individuals with severe mental illness and substance use problems. Paper presented at the Second Annual NAMI/NKI Conference on Perspectives on Family Care Giving. March, 1998.

Haugland G and Alexander MJ (1998). Gender, mental illness and addiction. Presented at Yaeger Community Mental Health Center, Pomona NY, March 1998.

Alexander MJ and Haugland G (1997). Gender, mental illness and addiction: Rates, indicators and service use. Presented at the Tenth Annual NYS OMH Research Conference. December, 1997.

Alexander MJ and Haugland G (1997). Gender, mental illness and addiction: Rates, indicators and service use. Paper presented at the One hundred and twenty fifth Annual Meeting of the American Public Health Association. Indianapolis, IN, November, 1997.

Education: The investigators participated with Janet Chassman, the OMH Director of MICA Training, in planning a Spring, 1997 MICA Teleconference Series that was broadcast to 21 clinical sites in New York State. Dr. Alexander moderated and presented preliminary data from these studies in the first of the series, "Women, Addiction and Mental Health."