Report to Congress
REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE DISORDERS AND MENTAL DISORDERS
There is a wide variety of financing and organizational structures being implemented in a number of States to support individuals with co-occurring substance abuse disorders and mental disorders. The following information describes both a case study analysis and a general survey.
The NASMHPD/NASADAD Joint Task Force on Co-Occurring Disorders recently completed a case study analysis of the financing and organizational structures of nine integrated programs throughout the Nation. These case studies provide detailed analyses of the financing used to operate stable programs that are demonstrably sustainable over the long term. Some of these programs are operated within the public substance abuse treatment systems, others within public mental health. Still others are jointly administered. Both substance abuse and mental health block grant funds are used commonly. The report concludes by finding, among other things, that:
No agency external to the case study programs has indicated concern regarding block grant expenditures. Those case study programs that are receiving block grant funds are successfully using these "braided" [aggregated] funding streams to support integrated services for persons with co-occurring substance abuse disorders and mental disorders and tracking expenditures in a manner that is consistent with Federal law and SAMHSA policy. The most significant problem that has come to light regarding the use of SAPT and CMHS block grant funds as a result of this project is that funds from either source standing alone are insufficient to meet the needs of persons with serious mental illness, substance abuse and co-occurring mental health and substance abuse disorders [emphasis in original] (NASMHPD/NASADAD Task Force, in press).
The 15 State reports that follow are representative of the activities of States making flexible use of SAPT and CMHS Block Grants and other funds to provide innovative services, including integrated treatment, for individuals of all ages who have co-occurring substance abuse disorders and mental disorders. These are not the only States using CMHS and SAPT Block Grant funds for these purposes; they are included in the report as representative examples of how States make innovative use of multiple funding sources to serve people with co-occurring disorders. All of the States are at various stages of addressing the issue of co-occurring disorders. A summary of these efforts in matrix form is included at Appendix V.
Current SAPT Block Grant reporting and auditing regulations do not require States to provide data about services provided to individuals with co-occurring mental disorders. Consequently, the State-specific information in this chapter of the report has been provided voluntarily as part of a survey of States about the use of these funds to support the treatment of individuals with co-occurring disorders.
The SAPT and CMHS Block Grants have been used creatively to promote the development of services for people with co-occurring disorders. The original impetus for the Arizona Integrated Treatment Initiative was a SAMHSA Community Action Grant for Service System Change, coupled with other resources, including State appropriations and tobacco settlement funds.
Recognizing that individuals with co-occurring disorders were commonly found in both substance abuse and mental health service settings, the Arizona Department of Health Services' Division of Behavioral Health Services launched a major initiative in 1999 to develop a best practice treatment model for individuals with co-occurring disorders. The result was a statewide refocusing of service practices in the behavioral health care system.
In particular, the State chose to pursue a consensus-based practice development model to identify the principles and practices of integrated treatment within Arizona, with the knowledge that implementation of this model would vary within the State based on local resources and the characteristics of the individuals being served. Among the outcomes of this effort were:
· New Contract Language. Contracts for regional behavioral health authorities were revised to include language regarding co-occurring disorders consistent with that contained in the CMHS Block Grant statute.
· New Policies and Guidelines. A work group of local and national experts developed Service Planning Guidelines for Co-Occurring Disorders and revised the State's eligibility policy for people with serious mental illnesses. The new policy expedites entry into services, regardless of concurrent substance use, and allows for an expanded time frame to gather necessary records. This means that individuals are not denied eligibility based on the inability to clinically differentiate multiple disorders or for lack of information.
· Consensus-Based System Change. One of the most significant findings of the Arizona initiative was that consensus-based system change encourages and sustains community action. System planners determined that had the initiative been developed in isolation at the State level and simply mandated by administrative requirement, the level of community "buy-in" needed to make change happen simply would not have taken place.
The California State Departments of Mental Health and Alcohol and Drug Programs entered into an interagency agreement in 1996 for a three-year period that was later extended for an additional year to fund four dual diagnosis demonstration projects using their respective Block Grant funding. This initiative was an outcome of the States' Dual Diagnosis Task Force. To adhere to Federal block grant requirements, both Departments worked with Federal liaisons to secure approval for the proposed process and to ensure a clear audit trail to each of the separate funding sources that supported the demonstration programs. While the process was approved by Federal officials, the conduct of the process and reconciliation of expenditures both proved difficult.
Selected grantee counties were required to match CMHS Block Grant and SAPT Block Grant funds with other funds, including State and local monies, pursuant to the selection criteria of the Request for Application.
The dual diagnosis demonstration projects served more than 950 individuals-including children, adolescents, adults, older adults, people who were homeless, and people who were involved in the criminal justice system. Of that number, 479 clients consented to participate in research activities. Outcomes included improvements in psychiatric functioning, access to mental health treatment, quality of life, and physical health treatment, and decreases in substance abuse and criminal justice costs. The demonstration spanned four years (1997-2001). All four counties have continued (and in some cases, expanded) program services funded by a combination of local and Federal dollars. The final evaluation report of the demonstration projects has not yet been distributed by the two State Departments.
In 1995 the State of Connecticut created the Department of Mental Health and Addiction Services (DMHAS) as the Single State Agency for both mental health and substance abuse services for adults. The Connecticut Department of Children and Families (DCF) is charged with the care of youth for behavioral health services.
SAPT Block Grant funds are distributed across all DMHAS-funded substance abuse treatment programs, including programs that provide addiction services for people with both substance abuse and co-occurring mental disorders. DMHAS, in coordination with DCF, uses CMHS Block Grant funds to fund and administer services for youth with serious emotional disturbances and adults with serious mental illness. Over the past several years, both an Alcohol and Drug Policy Council and a Mental Health Policy Council, with broad stakeholder representations jointly address policy and service issues related to the planning and coordination of adult and children's behavioral health services including those persons with co-occurring disorders.
DMHAS has directly focused SAPT Block Grant funds to provide services to adults with co-occurring substance abuse disorders and mental disorders in three methadone maintenance programs. These programs have implemented screening and assessment protocols to help identify clients with co-occurring mental disorders. Clients identified as possibly having a mental health disorder receive a full psychiatric assessment.
Clients determined to have a mild or moderate mental illness are seen by an on-site psychiatrist for medication review. They are assigned to a dual diagnosis counselor, and receive ongoing case management. The counselors also provide intensive, individual, or group counseling to these clients. Individuals diagnosed with a serious mental illness are referred to appropriate mental health services; care is coordinated across the two programs.
DMHAS continues to explore ways to enhance access to appropriate care for people with co-occurring substance abuse disorders and mental disorders. Various policy making and planning bodies within the State are involved in ongoing discussions regarding care coordination and implementation of best practices. The State has used State general fund dollars and other non-Block Grant resources to promote a coordinated system of care for individuals with co-occurring disorders.
In fiscal year 2000, Maryland developed three co-occurring disorders programs serving youth, young adults, and people who are homeless. Two projects provided co-occurring outpatient services and outreach to American Indian and Hispanic community groups. Services included educational activities and referrals to treatment.
The third project developed transitional programs for adolescents and young adults (aged 16 and older) with co-occurring substance abuse disorders and mental disorders, and provided comprehensive clinical services and rental assistance. Funding for these programs, identified as continuing activities in the fiscal year 2003 State Block Grant application, includes a match of CMHS Block Grant by State monies. No SAPT Block Grant funds are used for these programs.
Four localities in Michigan undertook special initiatives to develop integrated service delivery models, promote in-service cross-training, hire outreach staff, and enhance consumer support systems for programs serving individuals with co-occurring substance abuse disorders and mental disorders. One program developed a fully integrated service delivery model and continues to provide cross-training of staff to address the continuity of care from assessment to recovery. Services include individual and group therapy and education about coping with substance abuse disorders and mental disorders, drug interactions, and recovery.
A second project was designed to enhance services to consumers, emphasizing relapse prevention and maintenance of ongoing recovery. The third project provided in-service training for agency staff on the stages of recovery, provision of relevant interventions at different stages of treatment, and relapse prevention.
The fourth project hired a community-based outreach worker to coordinate prevention services with substance abuse outreach groups, mental health clinicians, and other entities. Funding for the four projects, which served approximately 71 adults, included CMHS Block Grant, SAPT Block Grant, State, and Medicaid monies.
Minnesota developed a statewide co-occurring disorders demonstration initiative to enhance strategic planning and cross-training efforts. Focus groups comprised of staff, consumers, and members of mental health and substance abuse advisory councils participated and developed a mission statement to coordinate co-occurring services. The strategic plan also identified barriers, including current legislation and separate funding streams.
Funding for this effort includes a mix of State and CMHS Block Grant monies. The planning and training activities have been ongoing for 3 years, and more than 200 professionals and consumers have participated. In addition, a staff person from the Chemical Health Division, funded by the SAPT Block Grant, is assigned to the Mental Health Division to address co-occurring mental illness and chemical dependency.
Missouri has used SAPT Block Grant funds to develop the Comprehensive Substance Treatment and Rehabilitation (CSTAR) Program for individuals with co-occurring substance abuse disorders and mental disorders. Each client receives a DSM diagnosis by a qualified diagnostician. Intensive individual and group counseling is combined with psychoeducational groups, residential support, family therapy, co-dependency counseling, child care, and case management as part of a continuum of treatment services.
All of the core CSTAR services are covered under Missouri's Medicaid plan, using the rehabilitation option under Missouri's Medicaid plan that allows services to be delivered in a variety of settings, including a client's home, and to be delivered by a variety of professional and paraprofessional staff. The Division of Alcohol and Drug Abuse certifies eligible agencies as CSTAR Medicaid providers, which allows them to offer services and obtain reimbursement.
Non-Medicaid eligible clients and non-Medicaid covered CSTAR services (e.g., child care, housing) are reimbursed by the Division through a combination of SAPT Block Grant funds and general revenue. Specialized CSTAR programs also provide integrated treatment to adolescents, women, and children.
Most CSTAR programs effectively treat people with co-occurring substance abuse disorders and mental disorders alongside the mainstream population. However, some programs have effectively aggregated separate funding streams, including SAPT Block Grant funds, to create specific programs for individuals with co-occurring disorders. Programs include both outpatient and residential. For example, the Daybreak Residential Treatment Center in Columbia is a long-term residential program that helps individuals make the transition from the State forensic mental health system back to the community.
The Missouri Department of Mental Health's Divisions of Comprehensive Psychiatric Services and Alcohol and Drug Abuse have jointly developed and implemented Core Rules for Psychiatric and substance abuse Programs. The rules identify common treatment principles and outcomes and administrative standards for both divisions' programming. In addition, these two divisions have created a Practice Guidelines Document for the Treatment of Adults with Co-Occurring Substance Use Disorders and Mental Illness. The guidelines focus on treatment of individuals with the most severe disorders.
The New Jersey Department of Health and Senior Services' Division of Addiction Services (DAS) provides services to people with co-occurring substance abuse disorders and mental disorders. The primary activity is the Screening Center Project, a collaborative effort between DAS and the Division of Mental Health Services.
The goal of the SAPT Block Grant-funded Screening Center Project is to improve the delivery of services to people with primary drug and/or alcohol problems, who present at three selected mental health screening centers. A newly-funded component of the Screening Center Project provides $25,000 to each of three screening centers to provide detoxification services specifically for individuals with co-occurring substance abuse disorders and mental disorders.
In addition to the Screening Center Project, DAS and the Division of Mental Health Services are undertaking other collaborative efforts. These include sharing of databases, jointly planned and executed training activities, shared funding of several treatment programs, and participation and collaboration with local-level substance abuse and mental health organizations.
In 1997, the State of New Mexico combined the Division of Mental Health and the Division of Substance Abuse into the Behavioral Health Services Division. The Division administers the SAPT and CMHS Block Grants and non-Medicaid mental health and substance abuse treatment funds. This integration has fostered significant collaboration between disciplines in policy and program implementation.
SAPT and CMHS Block Grant funds, as well as State appropriations in mental health and substance abuse, are used to develop system capacity for people with co-occurring disorders. As part of a statewide managed care initiative, the Behavioral Health Service Division implemented a regional model of service delivery that includes the following features:
· Five regional contractors that are responsible for the delivery of continuum of care in mental health and substance abuse treatment;
· Comprehensive Behavioral Health Standards established by the Division to guide service delivery, network management, and performance/outcome requirements; and
· A Behavioral Health Information System to monitor contract compliance and service delivery protocols through standardized reporting and site visits.
Because New Mexico's system is based on the assumption that co-occurring disorders are an expectation and not an exception, both substance abuse and mental health treatment programs must screen all individuals for the presence of both disorders on a routine basis. All programs employ a "no wrong door" approach that welcomes and supports the individual. In addition to screening, standard practices include assessment by appropriately licensed practitioners, integrated treatment planning, and direct services for both substance abuse disorders and mental disorders provided at the same time.
Some programs for individuals with co-occurring disorders have the in-house capacity to deliver services for both disorders; others coordinate services as part of a network of community partners. In addition, the system includes the capacity to address treatment and service needs throughout the entire continuum, including residential and hospital-based levels of care. The goal is to create a system that meets the standards of accessibility, integration, continuity, and comprehensiveness (Minkoff, 1998). A more comprehensive report on New Mexico's integrated services can be obtained by contacting SAMHSA's Office of Program, Planning, and Budget at (301) 443-4111.
Since 1998, the New York State Office of Mental Health (OMH) and the New York State Office of Alcoholism and Substance Abuse Services (OASAS) have worked together to improve the proficiency of both systems of care in treating individuals with a broad range of co-occurring substance abuse disorders and mental disorders along the full continuum of severity of disorder.
In 2001, the two agencies launched a regional training series for clinical supervisors, attended by more than 600 individuals across the state. The agencies are now conducting validation studies on two instruments to establish systemwide screening and assessment of co-occurring substance abuse disorders and mental disorders. To better align the systems of care within a particular locality, OASAS and OMH are supporting county-level Dual Recovery Coordinator positions in selected counties.
The commissioners of the two agencies convened the Quadrant IV Task Force-composed of clinicians, trade associations, local government representatives, and consumers-to identify barriers to more integrated models of care. Based on the Task Force report issued in 2001, the State held regional forums to build consensus around the report's recommendations and planned demonstration projects of the New York Co-Occurring Framework Model.
In fiscal year 2001, a New York special initiative launched two projects for people with co-occurring substance abuse disorders and mental disorders; one for adolescents and one for adults. The CMHS Block Grant is the primary funding source for these projects and is aggregated with local, State, and Medicaid monies. New York State encourages local mental health programs to bill for Medicaid-reimbursable services and provides local assistance funding, as well. Both programs have been in operation for nearly 2 years. The adolescent program is a partial day program for youth ages 14 to 18, providing milieu, group, individual, and family therapy. Drug screening occurs on a regular basis. The adult program is a self-help, peer support/advocacy program that emphasizes that clients take an active, responsible role in their recovery. Services include a drop-in center, outreach and advocacy, and peer support groups.
Oregon has been working toward improvements in delivery of services to persons with co-occurring disorders for over 15 years. Two statewide task force initiatives, one in 1986 and the other in 2000, have supported these developments. Like many other states, Oregon recognized the challenges and risks in promoting the dual recovery process for persons who experience alcohol/drug and mental health problems. There are now co-occurring program efforts in nearly all of the 36 counties with more than 60 different agencies providing some level of integrated service. Most of the funding continues to be categorical and there are continuing challenges in blending services at the local level while maintaining administrative and fiscal accountability to State and Federal regulations. The State has taken a lead role in adjusting administrative rules to eliminate unnecessary contradictory requirements and clarifying misconceptions about the necessity for separate assessments and treatment plans.
Oregon has a number of programs which are dually certified as alcohol/drug and mental health providers. These counties, such as Benton and Clackamas, receive a combination of Federal block grant funds for both substance abuse and mental health as well as state General Funds and Federal Medicaid mental health funding and to a lesser degree Medicaid funds for alcohol/drug treatment services through "Fully Capitated Health Plans" under the Oregon Health Plan. Using this combination of funding sources and within State and Federal regulatory requirements, services are then provided in an integrated manner to persons with co-occurring disorders. Examples of integrated services include unified assessment and treatment planning (for example in Benton County) which meet the requirements for both systems of care. Other examples include integrated group treatment (for example, in Clackamas County) provided by dually approved staff. Integration of services in Oregon are actually provided at the local level consistent with separate funding and administrative requirements.
Oregon has also developed draft guidelines which describe co-occurring substance abuse disorder and mental disorder "capable" and "enhanced" care. These guidelines were developed with input from both mental health and alcohol/drug staff and are one of the outgrowths from a statewide dual disorders work group which released its report and recommendations 2 years ago. The State's Office of Mental Health and Addiction Services is working toward the completion of many other recommendations including the development of a common enrollment form for persons who receive integrated treatment and improved data collection efforts. These initiatives are funded at the State level by the integrated state level office (OMHAS) and at the local level by Local Administration funds which have few if any administrative barriers to supporting integrated service systems.
In 1997, the Office of Mental Health and Substance Abuse Services in the Department of Public Welfare and the Bureau of Drug and Alcohol Programs in the Department of Health jointly sponsored a statewide Mental Illness and Substance Abuse (MISA) Consortium to examine integrated approaches in working with people who have co-occurring substance abuse disorders and mental disorders. Stakeholders from the mental health and drug and alcohol systems participated. The group's 1999 report recommended service and systems integration in four areas: assessment, professional credentialing and training, service standards, and adolescent services. Pennsylvania's MISA Pilot Project is the embodiment of those recommendations.
The MISA Pilot Project is a product of a collaboration between the State Departments of Health and the State Department of Public Welfare. Designed to promote systems and services integration for individuals with co-occurring substance abuse disorders and mental disorders, the project is composed of five county systems and a network of 11 providers offering integrated services. The network continues to expand as additional providers meet the required integrated service criteria. The projects total funding is $3.3 million annually and comes from the combined resources of three funding sources: State Intergovernmental Transfer Funds, CMHS Block Grant Funds, and the SAPT Block Grant Funds. Traditional reporting mechanisms are used for tracking and accountability.
Based on the consortium's recommendations, the State issued a solicitation for pilot projects to interested county mental health administrators and substance abuse directors. Available funds were to be used as seed money for development of program models that combine resources and expertise from both the community mental health and drug and alcohol systems. Four adult and one child/adolescent proposal were selected for funding.
Mental health and drug and alcohol funds have been allocated to the projects over a 2-year period, with an additional year for evaluation by the Center for Mental Health Policy and Services Research at the University of Pennsylvania. All pilot projects provide a varying number of services that meet criteria for enhanced/integrated services for co-occurring disorders.
The pilot projects are being evaluated to determine the impact of integrated treatment and systems of care on client outcomes; the impact on client satisfaction; the potential of specialized co-occurring disorders integrated treatment and support services; and best practice models of system integration, representing a variety of strategies that can be replicated for adult and adolescent services. Ultimately, the projects are expected to generate ideas for future policy and program development and identify potential funding sources for co-occurring disorders services.
The Texas Commission on Alcohol and Drug Abuse and the Texas Department of Mental Health and Mental Retardation created and funded a dual diagnosis coordinator position in 1995 to help ensure coordination between the two agencies. This position is funded with SAPT and CMHS Block Grant and general revenue funds. These monies also are funding 16 dual diagnosis projects throughout Texas.
The Commission on Alcohol and Drug Abuse purchases "dual diagnosis specialized services" to offer a coordinated approach to the delivery of integrated substance abuse and mental health services. The programs link patients to mainstream substance abuse and mental health services through research-based engagement strategies, and provide specialized dual diagnosis training and case consultation to service providers.
The target population includes people with substance abuse or dependence and a serious mental illness, including schizophrenia, major depression, and bipolar disorder. The State requires that "dual diagnosis specialized services" respond competently to age, gender, sexuality, geography, and culture for all people needing services in Texas. The Commission also provides statewide conferences on co-occurring disorders throughout the year to train staff and expand capacity to serve this population.
The Texas alcohol and drug and mental health agencies also have implemented significant system changes. To strengthen the ability of substance abuse providers to meet the multiple needs of people with co-occurring disorders and their families, the Commission on Alcohol and Drug Abuse has adopted statewide rules and regulations which require that mental health expertise be incorporated into existing programs and/or coordinated with other providers. These rules address requirements, including those for screening and admission, assessment, and treatment services for facilities licensed by the Commission. The two agencies operate under a Memorandum of Understanding (MOU) that addresses principles and practices for treating individuals with co-occurring disorders.
In May 1996, then-Governor Tommy Thompson created the Blue Ribbon Commission on Mental Health to examine the mental health delivery system and propose changes that fostered system effectiveness in an environment emphasizing managed care, client outcomes, and performance contracting. The Bureau of Substance Abuse Services and the Bureau of Community Mental Health are currently working cooperatively to develop a coordinated and flexible managed care model of service delivery, that includes the design, implementation and evaluation of a single entry point for consumers of mental health, alcohol, and drug services. The initiative emphasizes recovery principles and a consumer-focused approach with long-term care enrollees. The target group for this model includes individuals with severe and persistent mental illness, including individuals in that group who have co-occurring disorders.
During fiscal year 2000, Wisconsin developed a coalition to address co-occurring substance abuse disorders and mental disorders among the aging population. Five regional training sessions with over 450 participants in attendance educated about, and enhanced coordination of, mental health and substance abuse interventions, including the provision of integrated treatment, for older adults. Both the coalition and training efforts have been in operation for approximately 2 years. Funding is aggregated from multiple sources, including the CMHS Block Grant.
In addition, the Bureau of Substance Abuse Services used SAPT Block Grant funding to develop eight women-specific treatment programs that either provide or refer their clients to qualified mental health services. Coordination of mental health services for substance abuse clients is required for State program certification.
Wyoming developed both a statewide cross-training initiative and a strategic planning process to address the treatment of co-occurring substance abuse disorders and mental disorders among adults and adolescents. A statewide task force of private and public partners, including mental health and substance abuse treatment providers, developed an integrated treatment model for people with co-occurring disorders. Cross-training efforts began in 2001.
The 2002 Wyoming legislature passed and the Governor signed a law requiring cross-training of clinical staff throughout the State beginning July 1, 2002. Training programs will be held in multiple regional locations to reach as many staff as possible. Accompanying rules, regulations, and standards will be in effect December 31, 2002. State funds will support cross training efforts. In addition, working together, the State Mental Health and Substance Abuse Divisions will develop a best practice treatment manual and guidelines for use by all staff treating people with co-occurring substance abuse disorders and mental disorders in Wyoming. In addition to adults, separate sections will address special issues of women and adolescents with co-occurring disorders. The CMHS Block Grant provides funds for these activities and, in fiscal year 2003, Wyoming plans to use CMHS Block Grant funds to develop and demonstrate a co-occurring disorders service model. The SAPT Block Grant funds the substance abuse staff involved in these collaborative efforts.
A number of States have sought to develop programs focusing on the issue of co-occurring substance abuse disorders and mental disorders in children and youth. Highlights of some of those activities follow.
· Alabama convened a task force to examine service delivery gaps for children diagnosed with substance abuse disorders and mental disorders.
· Arkansas provides mental health case management services, referrals to detoxification and substance abuse treatment, and a program that serves children with substance abuse disorders and mental disorders at a chemical dependency treatment program.
· Colorado's Interagency Advisory Committee on Adult and Juvenile Correctional Treatment is addressing co-occurring disorders in adults and juveniles involved with the justice system.
· Maine's initiative to address juvenile co-occurring disorders will include unit-based treatment teams to deliver mental health services integrated with education and substance abuse disorder services.
· Nebraska has initiated a pilot project of integrated care to address co-occurring substance abuse disorders and mental disorders in children.
· North Carolina has an integrated system of care for adults and youth with co-occurring disorders that includes comprehensive assessment, case management, counseling, monitoring of medication, and substance abuse and relapse prevention.
· Oregon is working with the New Hampshire-Dartmouth Psychiatric Research Center to provide co-occurring disorders training and research. The State has also developed additional services for transition-age youth (ages 18 to 24) with co-occurring substance abuse disorders and mental disorders.
· Tennessee provides case management services to adults and children with co-occurring disorders through inpatient and outpatient programs.
· Virginia has aggregated eight funding streams to identify, intervene, and create services for young people with co-occurring disorders.
· Washington State has created a treatment guide for adults and youth titled How to Provide Integrated Services, based on the NASMHPD/NASADAD conceptual framework.
· West Virginia is developing plans to deliver comprehensive and integrated co-occurring disorders services to children and families.
In addition, the Community Guidance Center of the Commonwealth of the Northern Marianas, supported by the CMHS Block Grant, provides services by an interdisciplinary team to adults and children with co-occurring substance abuse disorders and mental disorders. The Virgin Islands provides psychological assessments, counseling, day treatment, psychosocial rehabilitation, and case management for adults and youth with co-occurring disorders.
This page was last updated on 22 October, 2002
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