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An Integrated Model for the Treatment of People with Co-occurring Psychiatric and Substance Disorders by Kenneth Minkoff, M.D.; Choate Health Management, Woburn, Massachusetts, USA Mental illness and addiction frequently occur together but have traditionally been treated separately ? often in isolation and unsuccessfully. Dr. Kenneth Minkoff, a dynamic speaker and nationally known expert in dual diagnosis, outlines how care can be integrated despite differences in treatment philosophy. Well-versed in both the mental health and substance abuse systems, Dr. Minkoff illustrates how each system can learn from the other. He discusses an integrated model for helping conceptualize a hopeful path to dual recovery.This article describes research-based principles of successful treatment interventions in individuals with co-occurring disorders. These principles are placed in the context of integrated model of service delivery that utilizes a common language or treatment philosophy that makes sense from the perspective of both mental health treatment and substance disorder treatment fields.
The article begins with an overview of the clinical and programmatic dilemmas faced by clinicians in treating these ?dually diagnosed? individuals and then enumerates 7 principles of treatment. These are: (i) dual diagnosis is an expectation, not an exception, within any of the 4 subtypes of comorbidity (using a sub typing model based on high/low severity of each disorder); (ii) the most significant predictor of treatment success is the provision of an empathic, hopeful, continuous treatment relationship in which integrated treatment and care coordination are provided over time; (iii) within the context of this relationship, care taking and case management are balanced with empathic detachment, empowerment and confrontation at each point in time; (iv) within this ongoing treatment context, both mental illness and substance disorders are considered primary, and integrated dual primary treatment is provided; (v) both mental illness and addiction are examples of not just random primary disorders, but chronic biological mental illnesses which can be understood using a disease and recovery model; (vi) the specific treatment interventions; as a result, there is no single correct intervention in this model. For each individual, the correct treatment must be matched to subtype, diagnosis, phase of treatment and extent of patient motivation and disability; and (vii) within a managed-care system, these interventions must be further individualized by a discrete level of care assessment for each disorder. These principles provide a template both for developing practice guidelines to determine individualized clinical treatment matching, as well as providing a template for large-scale system initiatives for the creation of comprehensive continuous integrated systems of care, and for assigning roles for each type of program within those systems. These large systems initiatives are currently underway in several US states, and provide a laboratory for further research on this model.
During the past two decades, the problem of providing successful treatment to individuals with co-occurring psychiatric and substance disorders (ICOPSD) has emerged with considerable energy in both the mental health system and the substance disorder treatment system. Increasing volumes of data have supported the impression of clinical experience in both systems that ICOPSD have poorer outcomes across multiple domains, as well as being difficult to serve in traditional treatment venues. Specifically, ICOPSD are more likely to relapse and be rehospitalized, to be treatment resistant and noncompliant, medically involved (e.g. HIV infected), criminally involved, and homeless, as well as impulsive, suicidal and violent.1-6 In addition studies in managed-care systems have identified ICOPSD as being over represented in populations of high utilizers of scarce systems resources, in both public and private sector systems. 7, 8
Successful treatment and disease management of either substance disorders or psychiatric disorders separately is highly challenging. Both disorders are chronic, relapsing, stigmatizing and potentially disabling. In addition, both disorders involve alteration of the individual?s mental status, so that disease management strategies are targeted at someone who is cognitively impaired, possibly with poor reality testing, and who may not adequately recognize the seriousness of his or her condition.
When the two illnesses co-occur, the problems of disease management are compounded dramatically. This occurs not only because of the potential for the two types of disorders to interact and create mutual symptomatic exacerbation, but also because of the fact that ICOPSD are essentially ?system misfits? who dare to have more than one disorder in systems of care that are designed to deal with a distinct primary mental health or substance disorder only. 9 Furthermore, managed-care initiatives in behavioral health systems during the past decade have added a layer of funding complexity to the already difficult clinical, programmatic, and philosophical issues that result from intersystem conflict.
Fortunately, accumulating research ? as well as clinical experience ? over the past two decades, addressing comorbidity in both populations with serious mental illness and complex addicted populations (with less serious but still problematic co-occurring mental disorders), has begun to identify a variety of principles that guide successful intervention. These research and clinical findings have been sufficiently elaborated to permit the development of expert consensus on an integrated model and standards of care for co-occurring disorder management in managed-care systems. This model, in turn, provides a template on which to base further clinical and systems research. The principles and standards, as well as the model, were disseminated in an expert consensus panel report generated by the Substance Abuse and Mental Health Services Administration, as part of its ?managed care initiative.?
This article reviews those principles and illustrates their application, both to the model and to strategies for system change.
First Principle
Comorbidity is an expectation, not an exception.
