# Presentation: 528945

## The Co-occurring Matrix forMental and Addictions Disorders

- Richard Ries MD
- Professor of Psychiatry and Director, Division of Addictions, University of Washington Dept of Psychiatry and Behavioral Sciences;
- Director of Out-patient Psychiatry, Addictions and Dual Disorders Programs, Harborview Medical Center, Seattle, Wa
- Medical Director, Washington State Division of Alcohol and Substance Abuse
- rries@u.washington.edu

## Why was the Co-occurring Matrix developed?

- Most early “dual disorder” research dealt only with those with Severe and Persistent Mental Illnesses in MHC’s
- A method and graphic was needed to describe other populations in MH and Addictions settings
- The “Matrix”  is simple and relates two Illnesses/Systems...
- Mental Health vs Addictions
- At two severities ....Low vs High
- Creates Chi Square combinations LL, LH, HL, and HH
- But do the “severities” mean Illness Severity, or Service Need?

## Adopted by various states and national organizations

- First published as a model by Ries ’93
- May have spread or been independently developed in Connecticut, New York, others
- Adopted as state model by New York ’95
- Adopted by State Directors: NASADAD/NASMHPD, June ’98 as national model for co-occurring disorders treatment

## The Four Quadrant Framework for Co-Occurring Disorders

- A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co-occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002)
- Not intended to be used to classify individuals (SAMHSA, 2002), but  . . .

**Less severe****mental disorder/****less severe substance****abuse disorder**

**More severe****mental disorder/****less severe substance****abuse disorder**

**More severe****mental disorder/****more severe substance****abuse disorder**

**Less severe****mental disorder/****more severe substance****abuse disorder**

**High severity**

**High severity**

**Low****severity**

## More severe

**IV**
***More severe***
***mental disorder/***
***more severe***
***substance***
***abuse disorder***
***Locus of care:***
***State hospitals,***
***jails/prisons,***
***emergency rooms, etc.***

**III**
***Less severe***
***mental disorder/***
***more severe***
***substance***
***abuse disorder***
***Locus of care:***
***Substance abuse system***

**I**
***Less severe***
***mental disorder/***
***Less severe***
***substance abuse disorder***
***Locus of care:***
***Primary health care settings***

**II**
***More severe***
***mental disorder/***
***less severe***
***substance***
***abuse disorder***
***Locus of care:***
***Mental health system***

**High**** Severity**

**Low Severity**

**High**** Severity**

***Alcohol and other drug abuse***

***Mental Illness***

## TABLE OF CO-OCCURRING PSYCHIATRIC AND SUBSTANCE ABUSE RELATED DISORDERS IN ADULTSWashington State

*Consultation between systems*
- Generally not eligible for public alcohol/drug or mental health services
**Low to Moderate Psychiatric Symptoms/Disorders**
**And**
**Low to Moderate Severity Substance Issues/Disorders**
- Services provided in outpatient chemical dependency or mental health system

**LOW - LOW**

## ASAM  PPC 2 RPatient Placement Model

- Addiction
- Addiction Only
- Addiction based dual capable
- Addiction based dual enhanced
- Mental Health
- MH only
- MH based dual capable
- MH based dual enhanced
- There are 6 ASAM dimensions

## Other “Systems” Axes

- Medical
- HIV
- Criminal Justice
- Homeless
- Developmental/Retardation
- Illegal Alien

## Other Dual Disorder Patient subtypes

- Wallen M ’89            ..................SMI, PD, Sub Ind, Others
- Ries ’93                    ..................Beginning Low High matrix
- Lehman A et al  ’94     ..................SMI, Non SMI, Sub Ind, PD
- Dixon L  et al  ‘97      ..................Prim/Secondary Psych
- Zimberg 99                ..................Sub Ind, Longer term etc

## Though designed as a “Services” schematic:

- Practitioners want clinical LH definitions for dispositional purposes.
- Agencies want clinical LH definitions so they can characterize their mix of pts, design programs to match
- States want LH definitions so they could compare different mixes of pts in agencies, regions, counties etc
- Feds want to compare states

## High Severity Psychiatric Symptoms/Disorders

- Severe and persistent mental illness (Schizophrenia, Bipolar, Major Depression w/psychosis, serious PTSD, Severe Personality Disorders)
- Demonstrated patterns of substance use, misuse or abuse
- Frequently served in outpatient mental health agencies, mental health crisis response services, and/or inpatient psychiatric settings.

**Low to Moderate Severity Substance Issues/**
**Disorders**
**Wa state schema**

## Studies of site (systems)  specific co-occurring subtypes

- Hein ’97          MH... more Schiz               Addict...   No Schiz
-        outpt
- Primm             MH... More Schiz               Addict...    No Schiz
-       outpt
-                                       No Anx                                     More Anx/Dep
- Havassy          MH...Schiz 43%                 Addict...   Schiz 31%
-       Acute                                                               remarkably few diffs
- These type of studies document the type of and the “integration” practices of the communities which they study

## However NO Co-occurring Matrix  published data exists 

- About its use as a “Systems” tool or concept
- About its use as a “Clinical” tool
- L/H definitions are conceptual and have not been operationalized for either Systems or Patient cases... _ie hard to research_

## But there are some pilot studies:

- Gabriel R et al ’04
- Ries R et al ‘04

## Project SPIRIT: Seeking Pathways Into Receiving Integrated Treatment Client Outcomes From a Local CSAT-Funded Study of Co-Occurring Disorders Treatment 

**RMC Research Corporation ****Portland, Oregon**
**Principal Investigator: Roy M. Gabriel, Ph.D.**
**Project Director: Kelly Brown Vander Ley, Ph.D.**
**     ****Outcome Analyst: Jennifer Lembach**
**Data Collection Coordinator: Gillian Leichtling**
**A Presentation at the Northwest Regional Substance Abuse Director’s Institute in “Lessons on Integrating Substance Abuse and Mental Health.”  Kah-Nee-Ta, Oregon, April 26-28, 2004**

## Mental Health/Substance Abuse Severity Quadrants

- Study participants classified into 4 mutually exclusive groups, defined by high or low severity on mental health and substance abuse disorders
- Because mental health and substance abuse are highly correlated, the low-low and high-high categories are the largest
- Gabriel R unpub ‘04

**Notes:**
1. We would expect such a small number in the low SA-high MH category because we’re studying SA agencies, not MH agencies.	

## Looking for Change Over Time in SA and/or MH Severity: Movement from One Quadrant to Another  (Gabriel R unpub 04)

- Reduction in MH severity, but not SA severity.
- Reduction in SA severity, but not MH severity.
- Reduction in both MH & SA severity.
- Reduction in SA severity, maintaining low MH severity.
- Reduction in MH severity, maintaining low SA severity.

- Low

- High

- High

- Low

**MH Severity**

**SA Severity**

- 3

- 2

- 1

- 5

- 4

## Findings (Gabriel R unpub 04) Changes Six-months post-Treatment Entry1

- In all, much positive movement
- Of 159 clients (65% of sample) who were in the high severity condition in one or both domains:
- 77% reduced to low severity in one or both
- 57% moved to the “Low/Low” classification
- What about the “SA masking MH problems” hypothesis?
- Not supported in these data
- Of 40 clients classified as Low MH, High SA severity, only 1 of 23 showed an increase in MH severity coupled with a decrease in SA severity
- 1 Vander Ley, Lembach, Gabriel & Lewis; APHA, 2003

## Relative vs Benchmarked Definitions of Low and High Severity

- Low MH in an acute psych ER might be HIGH MH in an addictions outpt clinic
- Low Addiction in a Methadone program might be High addiction in a primary care clinic
- Need for well described benchmarks

## But what really classifies a “case” as Low or High

- Mental Illness
- Diagnosis?
- Persistency?
- Disability?
- Alcohol/Drug
- Use and Abuse
- Dependence
- Chronicity/Disability

## Harborview Health Services Research Group

- Peter Roy-Byrne MD chief............Prim care x psych
- Richard Ries MD.........................Addiction, Co-occurring,Suicide
- Doug Zatzick MD........................Trauma, PTSD  Rx + Prev
- Mark Snowden MD......................Geropsych
- Kate Comtois PhD.......................Suicide, Borderline PD, High Utilizers
- Chris Dunn PhD...........................Motiv interventions AlcTrauma
- Joan Russo PhD..........................Data management, stats, DM
- Harborview Injury Prev Center
- NEW Center for Vulnerable MH, Addictions, Medical Populations

## Methods:  Attendings rate illness severities across 30 items on all admits and discharges

- Substance rating=
- 0= no substance use problems
- 1,2= substance use has led to only minor/infreq problems such as moodiness etc
- 3,4= qualifies for Substance Abuse with problems, but not dependence
- 5,6 = qualifies for dependence with compulsive use, consequences, and loss of control

## Definition:  	CD = 0-2 Low, 3-6 High		    Psychiatric = average of 	 				psychosis + depression + role dysfunction							3					      then split at > 3, < 3 (range 0-6)

**Total n = 5774**

**CD**

****

**Male = 69%**
**Median Age = 37**
**Median GAF = 45**
**Homeless = 36%**
**Hospitalized (vol.) = 9%**
**ITA = 4%**

**Male = 75%**
**Median Age = 38**
**Median GAF = 25**
**Homeless = 52%**
**Hospitalized (vol.) = 36%**
**ITA = 14%**

**Male = 50%**
**Median Age = 36**
**Median GAF = 50**
**Homeless = 16%**
**Hospitalized (vol.) = 12%**
**ITA = 7%**

**Male = 51%**
**Median Age = 39**
**Median GAF = 20**
**Homeless = 28%**
**Hospitalized (vol.) = 39%**
**ITA = 21%**

**n = 1651 **

**n = 1294**

**n = 1654 **

**n = 1175 **

## Acute vs Longer term problems:

**Many Substance Induced Psychoses or Suicide attempts will  ****ACUTELY**** require the highest level of care (Quad 4)**
**Often resolve in hours to days, now the case is Quad 3**
**Stress or  Medication  non-compliance may acutely cause**
** ****a  ****Low**** stable condition  to become a ****High ****Unstable mental condition**
**   ****( eg. stable depression to psychotic depression),  Quad 1 to 2 or 4**
**How to classify a severe alcoholic with 1day, vs 1 week, vs 1 mo, vs 1 yr vs 1 decade sobriety**
**Therefore the need to consider Acute vs  Longer term definition**

## Few Studies of “Substance Induced” psychiatric disorders

- Dixon L et al ‘97  ................one year follow up of Sub Induced showed
-                                               	more acute care, sub abuse, distinct from   					Prim psych.
- Ries R  et al ’01 .................Psych Attendings can tell the difference, most 				of the time, show construct validity in 					recognizing sub induced states

## Why Operationalize LH categories

- Clinicians and agencies could match pt to treatment
- Pt change in status with Treatment
- Categorizing agencies by pt type
- Comparing across agencies, programs etc

## Conclusions re the Co-occurring Matrix:

- Confusion about whether this is only a conceptual model vs whether it can or should be operationalized
- As a systems of care model or tool
- As a patient classification model or tool
- Problems with Acute vs Longer term classification of Services need or Pt type
- Problems with Substance induced psychiatric disorders
- Problems with Benchmarked vs Relative definitions of Low/High Severities