The National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders

ACKNOWLEDGMENTS. A joint statement on substance abuse disorder by the National Association of State Alcohol and Drug Abuse Directors and the National Association of State Mental Health Program Directors emphasizes establishing precedents in both substance and process. This document was created with all the participating State Mental Health Commissioners and State Alcohol and Other Drug Directors. They voluntarily suspended traditional positions to create an innovative framework for co-occurring disorders. Michael Couty (MO), Lewis Gallant (VA), Elizabeth Howell (GA), Thomas Kirk (CT), Sherry Knapp (RI), and Mayra Leonard (MA) were the State AOD Directors participating. Commission members include Sharon Autio (Minnesota), Stephen Mayberg, PhD, Marylou Sudders (also Minnesota), Roy Wilson, MD, and Tom Fritz (DE).

Jerry Carroll, PhD, Robin Clarke, PhD, Bert Pepper, M.D., and Marc Schuckit, M.D. provided valuable insight as well as direction, and both Associations are grateful to the Government Project Officers for their support and participation in substance abuse disorder. Dr Carol Coley and Dr Michael English from the Center for Substance Abuse Treatment (CSAT), the Center for Mental Health Services (CMHS). CMHS and CSAT's contributions should also be acknowledged. All our thanks go to them. Commissioner James Stone and his staff at New York University wish to acknowledge the NASMHPD and NASADAD. For the graphics in this document, the Office of Mental Health contributed. Paul Barreira, M.D., of the Massachusetts Department of Mental Health, is recognized for his contributions to substance abuse disorders.

As the author of the first draft of this document, we would like to express our gratitude to Susan Milstrey-Wells. She excelled in both her academic qualifications and her high professional standards. In addition to NASADAD, NASMHPD and other national associations for the treatment of substance abuse, important contributions were also made by many knowledgeable representatives from SAMHSA, the CMHS, and CSAT. The hard work of these individuals is deeply appreciated, even though they cannot be named here. In closing, we want to thank all Association staff members for their support in this effort. It would be inappropriate for me to express my gratitude to all those who have worked so diligently on the NASMHPD and NASADAD projects, particularly Bruce Emery, M.S.W., and Bob Anderson, respectively.

Brian Glover, NASMHPD Executive Director. John Gustafson, NASADAD Executive Director

Washington, D.C. March, 1999

EXECUTIVE SUMMARY. Psychiatric and substance abuse disorders co-occur in this country, and the cost to society must be addressed. Despite the long history of awareness and discussion of co-occurring disorders, there hasn't been much agreement on achieving systemic change.

In Washington, DC, the National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders, held on June 16-17, 1998, provided participants with an unprecedented opportunity to discuss this topic. Supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and two of its centres, the Center for Mental Health Services and the Center for Substance Abuse Treatment the meeting was co-sponsored by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD). A state mental health department representative, an alcohol and drug abuse agency official, and a Federal official on substance abuse disorder were among the invited participants.

A study conducted by the National Institute on Drug Abuse evaluated the current state of alcoholism and drug abuse treatment, including reviewing administrative, logistical, and funding arrangements made by state alcohol and drug abuse directors and mental health commissioners. As a collective result of the group's extensive experience, they framed discussions and shaped a change plan for the organization.

The number of Americans struggling with mental health and substance-related disorders is estimated to be between 10 million and 15 million per year (SAMHSA NAC, 1997). It's not just about numbers. Co-occurring disorders are associated with multiple health and social problems, requiring expensive care. In addition to incarceration, many face homelessness and a higher risk of becoming homeless.

There have been several factors involved in substance abuse disorder that have hindered dual-diagnosed patients from receiving appropriate treatment in the past. One of the most notable points is that co-occurring disorders are not responsible for one party. In mental health and substance abuse treatment, separate systems are in place, each with its treatment philosophy, administration structure, and funding mechanism. There is no easy transition between service settings for consumers nor providers in cases like this.

Suppose non-alcoholics and alcoholics with co-occurring disorders achieve any consensus on treatment and services. In that case, both communities need to come to terms with substance abuse disorder and develop a shared perspective. Toward this end, the National Dialogue participants developed a conceptual framework that looked at both the needs of individuals with co-occurring disorders and the system requirements for supporting them.

A co-occurring disorder is conceptualized as a multiple of symptoms and severity instead of a separate diagnostic entity. It adequately covers everything from substance abuse disorder to personality disorders. Specifically, it defines the coordination level needed to improve consumer outcomes, such as consultation, collaboration, or integration. Its flexibility makes it suitable to be adopted or adapted to work in any setting, regardless of whether co-occurring disorders are present.

The Framework Identifies Two Groups that Require Special Attention:

• Individuals, Particularly Children and Adolescents, are at risk of contracting more serious diseases.
• Substance abusers, individuals with mental illness, and even homeless people may be found in jails, forensic hospitals, emergency rooms, or streets.

Several factors contribute to poor outcomes in this group, including a lack of coordination in the care system.

A top-level focus on substance abuse disorder is required for an integrated services system for co-occurring disorders. Additionally, there should be a consumer-centered approach, cultural competency, and a “no wrong door” approach, i.e., the services must be accessible and available, regardless of where an individual enters the system.

Other Important Factors for Success Include:

• shared assessment and data tools.
• Staff trained in different disciplines.
• Flexible funding mechanisms.

To meet consumer needs comprehensively, the system must be structured in a coordinated manner regardless of its organizational structure.

Mental health, substance abuse, and primary health care systems should coordinate to provide services for those with co-occurring disorders. In the conceptual framework, substance abuse disorders require three levels of coordination. According to the degree of severity of a particular disorder, there are different levels of coordination. More intensive coordination is needed if effective service delivery is to be ensured.

The intensity begins with informal consultations, including mental health and substance abuse issues; progresses to formalized collaborations, which combine mental health and substance abuse into one setting and regimen; and ends with integration. Each of the three coordination steps requires a shared vision and ongoing commitment from both the project team and the team as a whole. It is also important to note that collaborations among multi-disciplinary service teams and shared treatment planning contribute to the effectiveness of all three coordination efforts.

Each of the key stakeholders involved, whether they were Federal agencies that sponsored the event, national associations that sponsored them, State commissioners and directors or substance abuse and mental health experts, plays an important role in system change. In dealing with substance abuse disorders, SAMHSA's Centers were encouraged to share best practice models. Recommended the states develop specific measures to stimulate, enable, and fund cooperative effort in addressing the needs of this population, and urged both NASMHPD and NASADAD to make co-occurring disorders a priority for their respective groups both. It was agreed that the framework would be used as a framework to continue a dialogue on co-occurring disorders.

A key commitment made by participants in the National Dialogue is that they will continue the work that was begun together and to include all relevant stakeholders, including communities, mental health care centres, drug treatment centres, and consumers, in efforts to advance improvement in health outcomes for people with co-occurring disorders. This action must be pursued with deliberate speed and appropriate care. Such an effort will be successful with a framework encouraging the Federal, State, and local governments to work together and provide appropriate care for substance abuse disorders.

INTRODUCTION. As well as having a significant impact on individuals' lives, families, health care delivery and costs, and society in general, the co-occurrence of mental health and substance use disorders hurts the quality of life as well. It has been long acknowledged and discussed how co-occurring disorders could be a challenge, but there has been little agreement regarding implementing the necessary systems change.

The National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders, held June 16-17, 1998, in Washington, DC, offered participants an unprecedented opportunity to address this critical issue. Co-sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and two of its centers, the Center for Substance Abuse Treatment and the Center for Mental Health Services, the NAADAD and NASMHPD both gave presentations and guided discussions during the meeting. State mental health commissioners and alcohol and drug abuse directors were among the invited officials, as well as experts and government officials.

This White Paper results from conversations between mental health commissioners and state alcohol and drug abuse directors, whose concerns cover a broad spectrum of treatment, administrative, and funding arrangements. This group of individuals represented States with separate mental health and substance abuse programs, States whose programs are combined, States in which both the mental health director and the alcohol and drug abuse director attended the meeting, large and small systems, and areas in urban, rural, and mixed systems. A change plan stemmed from the group's collective experience and extensive discussions.

There Were Ambitious Goals for The Participants. in Particular, They Aimed To:

• Define the group of people with mental illnesses and substance abuse disorders;
• Find out who is in this population;
• A successful service system that addresses the needs of these groups should have the following characteristics.
• You should propose strategies for moving this agenda forward.

Participants in the meeting developed a conceptual framework for addressing co-occurring disorders by defining the population and classifying specific populations. Using this framework, individuals with co-occurring mental health and substance abuse disorders are presented with comprehensive information regarding symptom severity, locus of care, and the level of service coordination necessary to address those needs. As a result, the possibility of future discussions about funding opportunities will also be considered.

Furthermore, the framework is flexible enough to match any service setting, even those without an integrated service capability.

Furthermore, Two Groups Should Receive Special Attention:

• In addition to jails and forensic hospitals, people with severe mental health disorders may be living on the streets or in emergency rooms and need fully integrated services to have positive outcomes.
• Presently, children and adolescents have fewer problems than adults but could develop worse diseases in the future.

The meeting itself represented the collective effort that was important for dealing with co-occurring disorders. The participants were all of the opinions that such a collective effort is crucial in improving the quality of life for people with co-occurring disorders. There are several contributing factors to the project's outcome that were clearly defined in terms of the roles of each of the participating groups. I am concerned that the Federal agencies, such as the Department of Defense, the Department of State, and the Department of Transportation, played a decisive role in bringing the group together. Co-sponsored and facilitated by the national associations, the state commissioners and directors determined the content and outcome of the meeting. The interactions between expert panelists and attendees were constructive, resulting in greater understanding of substance abuse disorders.

It was recommended that each group play a specific role in accomplishing the system change. Contributions: these contributions paralleled the idea that each group should play a role in achieving system change. SAMSHA can assist, and NASADAD and NASMHPD can prioritize this issue. The field of co-occurring disorders can be advanced with the help of researchers and experts. For a more effective system of care for people who have mental health and substance abuse disorders, more work will need to be done at the state and local level with policymakers, provider organizations, consumers, and advocates. Using the conceptual framework to develop community-specific solutions provides a valuable tool for addressing a community's needs.

It is intended to summaries the participants' discussion and the products developed during this project. There are several reasons for this, but the briefest one is that Section I describes, briefly, the characteristics of the population and a few of the historical barriers to providing care for people who have co-occurring disorders. Throughout Part II of this report, the framework is outlined using a model created by New York State based on a conceptual framework originally developed by the state.

In section III of the document, one of the goals of the researcher group was to outline desirable characteristics in a comprehensive system of care for people with co-occurring disorders, giving particular attention to the three forms of service coordination the researcher group defined, collaboration, collaboration and integration. As a final step, In Section IV, we provide recommendations for future strategies that may serve as a basis for translating the existing theoretical underpinnings of the conceptual framework into practice.

Included in the online version of the Working Paper is an appendix with a list of participants and expert panelists, a resource section, and a web page listing of relevant organizations. It is recommended that those interested in learning more about co-occurring disorders visit the sites above and contact their state commissions and directors and representatives from NASMHPD and NASADAD, with questions or concerns concerning substance abuse disorders.

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