Addressing Co-morbidity in the
         EAP Setting




      Bernie McCann, MS, CEAP
          Cambridge College
        ...
Learning Objectives:
1. Discuss EA competencies and skill set
   utilized in workplace substance abuse and
   mental disor...
Historical Development of EAPs
19th Century Influences:
        Employers: Welfare Capitalism
        Trade Unions: Commun...
Today’s EAPs are designed to impact:
                Organizational
                    Goals




                    EAP
...
EAP enrollments, 1993-2003
                    (in millions)
90
80
70
60
50
40
30
20
10
 0
     1993 1994 1995 1996 1997 1...
Enrollment in EAP
        1993-2003, by Type
60


50
                               52.8
40


30


20
                    ...
Current Challenges for EAPs
• Increased pressure on EAPs to demonstrate a unique
  contribution to enhanced workplace prod...
Major Factors on EAP Effectiveness

 Major shift from internal to external delivery of
   EAPs has resulted in:
   1) new...
Substance Use & Mental Disorders



         15.2                     15.4
        Million                  Million
      ...
Substance Abuse & Co-Morbidity
• Adult lifetime co-occurrence of mood,
  anxiety, anti-social personality disorders
  & se...
Some Explanations for Co-morbidity

 1. Substance-induced temporary mental
    conditions

 2. Substance use (extent varia...
Sadness vs. Depressive Symptoms in
Alcoholics/other addictions

• 80% Experience some level of sadness

• 30% - 40% meet D...
CODs in Insured People with SUDs
                    Of 774 patients in a large HMO:
                              Patient...
Mental Disorders in EAP Settings
• Generalized Anxiety Disorder*
• Post Traumatic Stress Disorder*
• Panic Disorder
• Soci...
Treatment of SUD & MH Problems - 2004
CODs: Clinical Implications

 More prevalent than earlier appreciated

 Related to reluctance to seek TX

 Implicated i...
Suicide as a risk factor for CODs
• 10.4% of adults who suffered a major depressive
  event attempted suicide, 14.5% made ...
Nicotine Dependence: a COD health cost factor
  • Smoking is the most preventable cause of death in
    American society. ...
Universal Screening “Widens the Net”
Screening vs. Assessment
• Screening - a process to identify an
  individual’s characteristics of problem drinking,
  subs...
COA EA Practice Standard: Assessments
  Clinical assessments should include:
    • Review of physical illnesses, somatic
...
EAP Best Practices – Co-occurring Disorders

• A comprehensive assessment for SUDs indicates
  a psychiatric assessment fo...
Enhanced EAP Worksite Approach

Pressure points for an EAP might include:
•   Increase screening for SUDs/MDs + CODs
•   I...
Enhanced Case Management for CODs
 Integrated SA & MH assessments

 Use of evidence-based

 motivational interviewing, ...
MI = Progressive Continuum of Support
                                               Follow-up

            Engage client ...
Maximizing EA Effectiveness in
Co-occuring SUD/MD Interventions
1.   Earlier screening for identification of risky drinkin...
Demonstrating Value to Employers

      •   Tell them about it – Starting with
          Orientation and Management traini...
Thanks for your attention
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Addressing Co Morbidity In The EAP Setting Cambridge College Class Slides

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These slides were used for a guest lecture to graduate students attending course on substance abuse counseling at Cambridge College in Boston, MA.

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Addressing Co Morbidity In The EAP Setting Cambridge College Class Slides

  1. 1. Addressing Co-morbidity in the EAP Setting Bernie McCann, MS, CEAP Cambridge College January 24, 2007
  2. 2. Learning Objectives: 1. Discuss EA competencies and skill set utilized in workplace substance abuse and mental disorders. 2. Review recent advances in evidence- based treatment and case management of CODs relevant to EA practice. 3. Illustrate how both a renewed emphasis & new information have the potential to increase positive COD outcomes in the EAP setting.
  3. 3. Historical Development of EAPs 19th Century Influences: Employers: Welfare Capitalism Trade Unions: Communal Brotherhood 1940s - Occupational Alcoholism Programs 1960s - Slow growth, mostly in mfg/indus sector 1970s - NIAAA recruits “Thundering 100” 1980s - ‘Broadbrush’ approach = ‘modern’ EAP 1990s - Expansion & Integration Managed Care, Work/Life, CISDs, etc. 2000s - Market Expansion & Product Shrinkage EAP as a Commodity – Price anemia, Quality issues
  4. 4. Today’s EAPs are designed to impact: Organizational Goals EAP IMPACT Health Claims Human Capital
  5. 5. EAP enrollments, 1993-2003 (in millions) 90 80 70 60 50 40 30 20 10 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2003
  6. 6. Enrollment in EAP 1993-2003, by Type 60 50 52.8 40 30 20 27.4 20.0 10 7.2 0 1993 2003 EAP only EAP + MBH
  7. 7. Current Challenges for EAPs • Increased pressure on EAPs to demonstrate a unique contribution to enhanced workplace productivity and health care cost containment; as an increased responsibility/accountability for safety-sensitive situations. • Current data on substance abuse, mental disorders prevalence and cooccurance of these conditions reveals many more Americans could benefit from intervention (at all levels). • Enhanced EA efforts to identify and assist those employees with cooccuring conditions has potential to demonstrate increased value and better client outcomes.
  8. 8. Major Factors on EAP Effectiveness  Major shift from internal to external delivery of EAPs has resulted in: 1) new “occupational profile” of EA providers; and 2) community-based provider network delivery less integrated with employee’s worksite & productivity  Increased market competition has diversified EA services and products (diluted effectiveness?)  Rise in overall health care costs = reduced access to TX for SUDs & MDs
  9. 9. Substance Use & Mental Disorders 15.2 15.4 Million Million 4.6 Substance Million Severe Use Mental Disorder lllness Only Only Co-occurring Disorders
  10. 10. Substance Abuse & Co-Morbidity • Adult lifetime co-occurrence of mood, anxiety, anti-social personality disorders & severe mental illness with substance abuse is approximately 50%. • The presence (and resolution) of co- morbid factors is a primary & critical success factor in sustaining recovery from substance use disorders.
  11. 11. Some Explanations for Co-morbidity 1. Substance-induced temporary mental conditions 2. Substance use (extent variable) may intensify prior psychiatric disorders 3. Some psychiatric disorders likely to increase risk factors for substance use disorders
  12. 12. Sadness vs. Depressive Symptoms in Alcoholics/other addictions • 80% Experience some level of sadness • 30% - 40% meet DSM criteria for ‘Depressive Episode’ • ‘Chicken or Egg?’; ‘self medication’? – little neurological evidence to resolve
  13. 13. CODs in Insured People with SUDs Of 774 patients in a large HMO: Patients without SUDs Patients with SUDs Depression 3% 29% Injury/Overdose 12% 26% Anxiety 2% 17% Lower Back Pain 6% 11% Headache 4% 9% Major Psychoses 0.4% 7% Hypertension 3% 7% Asthma 3% 7% Arthritis 1% 4% Cirrhosis (Liver) 0.1% 1% Source: Mertens JR, Lu YW, Parthasarathy S, et al. Medical & psychiatric conditions of alcohol & drug treatment patients in an HMO. Arch Intern Med. 2003;163: 2511 - 2517.
  14. 14. Mental Disorders in EAP Settings • Generalized Anxiety Disorder* • Post Traumatic Stress Disorder* • Panic Disorder • Social Phobias* • Obsessive-Compulsive Disorder • Dysthymia* • Depression *May actually be occupationally induced
  15. 15. Treatment of SUD & MH Problems - 2004
  16. 16. CODs: Clinical Implications  More prevalent than earlier appreciated  Related to reluctance to seek TX  Implicated in failure to engage in TX  Contributes to higher relapse rates for both SUDs & MDs
  17. 17. Suicide as a risk factor for CODs • 10.4% of adults who suffered a major depressive event attempted suicide, 14.5% made a suicide plan, 40.3% thought about killing themselves, and 56.3% thought that it would be better if they were dead. • Rates went higher when depression was co-occuring with alcohol or other drug abuse - rate of suicide attempts rose 14% percent among binge drinkers, and 20% higher among those who used illicit drugs. Source: SAMHSA Suicidal Thoughts, Suicide Attempts, Major Depressive Episode, and Substance Use Among Adults – JT Online Summary, 9/19/2006
  18. 18. Nicotine Dependence: a COD health cost factor • Smoking is the most preventable cause of death in American society. Nearly 1 in 5 US deaths results from the use of tobacco; more than 400,000 die from smoking in the U.S. each year alone. • Smoking actually kills more alcoholics than alcohol. Pharmacological interactions between alcohol & nicotine are critical determining factors in the very common co- occurrence of chronic drinking and smoking. • Cigarette smoking exacerbates alcohol-induced brain damage. Recent neuroimaging studies of chronic smokers have shown brain structural and blood-flow abnormalities
  19. 19. Universal Screening “Widens the Net”
  20. 20. Screening vs. Assessment • Screening - a process to identify an individual’s characteristics of problem drinking, substance abuse or dependency through established criteria, & which may indicate more in-depth assessment. • Assessment - more extensive analysis of substance use, abuse or dependency - specifically for level of severity, contributory factors, & any associated consequences.
  21. 21. COA EA Practice Standard: Assessments  Clinical assessments should include: • Review of physical illnesses, somatic variables, medical treatment • Use of alcohol and any other drugs • Behavioral and cognitive patterns leading to health risks • When appropriate: legal, vocational, and/or nutritional needs of employee Source: Intake, Assessment and Service Planning. Council on Accreditation Requirements, 2nd Edition XI.4.01
  22. 22. EAP Best Practices – Co-occurring Disorders • A comprehensive assessment for SUDs indicates a psychiatric assessment for presence of co- occurring disorders, and vice-versa. • Failure to address co-occurring disorders leads to shorter lengths of abstinence and more frequent relapses (an estimated 20 - 30% reduction in treatment effectiveness). • Treatment referrals, case management, aftercare and follow up should consider the duality of any co-occurring diagnosis to ensure effectiveness.
  23. 23. Enhanced EAP Worksite Approach Pressure points for an EAP might include: • Increase screening for SUDs/MDs + CODs • Increase worksite awareness efforts • Provide web-based information & referrals • Increase level of supervisory training • Expand support for workers in recovery
  24. 24. Enhanced Case Management for CODs  Integrated SA & MH assessments  Use of evidence-based  motivational interviewing, cognitive-behavioral and family counseling approaches  EAP as the primary, central case manager  More frequent, structured follow-up and/or compliance monitoring - à la Impaired Professional Committees in health professions
  25. 25. MI = Progressive Continuum of Support Follow-up Engage client in behavior change Establish action steps Review motivation for change Ascertain client goals Education Assessment Screening
  26. 26. Maximizing EA Effectiveness in Co-occuring SUD/MD Interventions 1. Earlier screening for identification of risky drinking, problem drinking, pre-morbid substance abuse 2. More comprehensive assessments for appropriate, cost-beneficial treatment referrals 3. Use of motivational interviewing for optimum intervention and maximum client compliance 4. Closer EAP case management & increased follow up to ensure greater adherence to treatment plans 5. Greater use of performance measures and outcome reports to support continued expansion of services.
  27. 27. Demonstrating Value to Employers • Tell them about it – Starting with Orientation and Management training • Incidence stats/Industry prevalence • Conduct a quantitative worksite study • Keep detailed records of services • ‘Cost-out’ services provided • Conduct case reviews of actual costs & outcomes, to demonstrate the savings/benefits of interventions
  28. 28. Thanks for your attention

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