Appendix B, RESOURCE MATERIALS

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Appendix B

The Resource Materials

A NATIONAL MEETING ON CO-OCCURRING MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER

JUNE 16-17, 1998 WASHINGTON, DC?

RESOURCE MATERIALS

I. Bibliographical Annotations:

The Center for Mental Health Services (1997). Annotated bibliography on the Dual Diagnosis Panel for Co-Occurring Mental and Substance Disorders. (Table of Contents and Introduction only, Full copy available on site).

II. Technical Assistance Documents from the Center for Mental Health Services:

The Center for Mental Health Services (1998). Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula for Psychiatric and Substance Use Disorders in Managed Care Systems. Managed care provider training and standards project report by the Center for Mental Health Services. (CMHS Publication). The contents of components 1, 2, and 3 are not included in the materials provided in the briefing packet. However, a full copy is available onsite. Center for Mental Health Services (1997). Advocacy for Homeless People with Mental Illness and Substance Abuse. (SAMHSA Publication) Rockville, MD.

The Center for Mental Health Services (1996). Developing intervention strategies for homeless people with mental illness and substance use disorder. Submitted for publication by the Center for Mental Healthcare Services in Rockville, MD (1996). Mental Illness and Homelessness: Preventing Homelessness. Published by SAMHSA (Draft), Rockville, MD.

The Epidemiology/descriptive Nature of Two Related Disorders:

Raphael E. Drake, Adolf Alterman, and Stuart Rosenberg. (1993). a Study on The Prevalence of Substance Use Disorders Among Seriously Mentally Ill Patients. Journal of Clinical-Community Mental Health, 29, 175-192. The purpose of this paper is to discuss the challenges associated with the detection of alcohol and other drug problems in patients with severe mental health. Current research findings, clinical guidelines, and recommendations are reviewed. Offers strategies to detect alcohol use and illicit drug use. R.C. Kessler, C.B. Nelson, K.A. McGonagle, M.J. Edlund, R.G. Frank & P.J. Leaf. (1996). A Comparative Study of Co-Occurring Addictions and Mental Disorders:

Impact of prevention on service utilization. American Journal of Orthopsychiatry, 66, 1, 17-31.

This article presents the results of the National Comorbidity Survey. According to the results, 51 per cent of those with a lifetime addictive disorder also had a lifetime mental health disorder. This is greater than the prevalence of mental disorder found in the NIHM Epidemiological Catchment Area Study. In addition, the NCS found that most people with co-occurring disorders had at least one mental disorder earlier than their first substance-related disorder. The general population has a high co-occurrence rate, and treatment probability is considerably higher.

National GAINS Center. (1997). This study is designed to investigate the prevalence of co-occurring substance abuse disorders and mental disorders in the criminal justice system. Delmar, NY,

Statistics published by the government show that mental health and substance abuse disorders are becoming more commonly diagnosed in criminal justice departments. There are currently more than 25 million people in federal remand prisons across the country. Mental health and substance abuse disorders affect half of the criminal justice system’s population. It provides information about jail detainees with mental illness and persons in jail with substance abuse disorders or both. Many people are frustrated with the number of people with serious mental illness who also abuse or are dependent on drugs in the general population mental illnesss. It is estimated that there are approximately 2.5 million people with serious mental health under community supervision in the U.S.

Schuckit, M.A., & Hesselbrock, V. (1994). What is the relationship between alcohol dependency and anxiety disorders? American Journal of Psychiatry, 151, 1723-1734.

The purpose of this paper is to critically examine the literature concerning the relationship between alcohol dependence and lifelong DSM-III-R anxiety disorders. The paper has stated that alcoholism and anxiety disorder interrelate in a complex manner showing mental health issues. Even though available data do not support the conclusion that there is an important relationship between alcohol dependence and lifelong anxiety disorders, some studies have been carried out that show similar results. Research on children whose parents are alcoholics and individuals without drinking disorders suggests that anxiety disorders do not precede alcohol dependence. Some studies have demonstrated high rates of comorbidity among alcoholics, including real anxiety disorders and temporary substance-induced anxiety disorders and mental health problems.

Service Delivery Design issues

Minkoff, K. (1997). Psychiatric and addiction services are integrated. The Public Sector Managed Mental Health Care. Harwood Academic Publishers, based in Amsterdam. 233-245. Psychiatric and addiction services should be integrated into this chapter to respond to the competitive demands of managed care. Integrated services are discussed, advantages and disadvantages, and an argument for integrated service delivery. A step-by-step process to implement the new program is provided, focusing on the organization’s philosophy and mission, agency structure, clinical program, and staff development.
Minkoff, K. (1991). Integrating Mental Health Care Program Components with Substance Abuse Services. Psychiatric Rehabilitative Services, 30, 13-27. This chapter develops a model healthcare model based on an integrated theoretical framework of dual diagnosis. NASADAD (1997). Information on Services for People With Co-Existing Mental Health and Substance Abuse Disorders. (NASADAD report submitted to CSAT).


Provides an overview of state-level NASADAD surveys of alcohol and other drug agencies and state mental health authorities. Describes how services are organized, designed, delivered, and funded at the state level for co-existing disorders. Provides state-specific information on co-occurring disorders. NASMHPD and NASADAD (1998). A Review of State Surveys and Case Studies of Mental Health and Substance Abuse Services. Report to HRSA from NASADAD and NASMOHD.

Study how States develop and implement policies and procedures to link services for mental health, substance abuse, and primary health care. It assesses structural barriers interfering with linkage efforts and strategies that States have employed to overcome them. As part of the report, three states describe innovative strategies for promoting links through case studies. Health Policy Forum of the United States. (1997). It is challenging to serve individuals with concurrent mental health and substance abuse problems: issue Brief, 718.

In this report, a roundtable discussion on the prevalence of co-occurring mental health and substance abuse disorders is summarized on April 14, 1998, in Washington, DC. The paper explores the challenges to effective mental health intervention for this population due to deinstitutionalization, homelessness and incarceration, and significant barriers. Several factors causing the increase in comorbidity were explored and dual diagnosis, homelessness and crime, and the connection between dual diagnosis and substance abuse. In addition, mental health and addiction are considered in the study. It also includes recommendations for prevention and treatment from the SAMHSA National Advisory Council. In addition to prevention and rehabilitation services for co-occurring mental and substance use disorders, both services are intended to provide rehabilitation services for those who have or might develop co-occurring disorders.

Osher, F. (1996). It is enhancing patient care by implementing a patient-centered and community focused service model that will increase patient satisfaction and safety. American Journal of Orthopsychiatry, 66, 1, 71-76.

They are recognized as a matter of frustration, high costs, and a detrimental effect on the quality of life, which has led them to be portrayed as co-existing addictions and severe mental health, begging for innovative and creative solutions when treating mental problems. The literature supports the effectiveness of integrated services of addiction and mental illness, based on both empirical research and clinical experience. Incorporating a system of integrated mental health and addiction services is likely to prove to benefit not only those who suffer from co-occurring disorders but also those who seek treatment for conditions other than substance abuse or addiction. (author)


National Advisory Council of SAMHSA. (1997). It is necessary to promote services for individuals with co-occurring substance and mental health disorders at risk or co-occurring conditions. Rockville. The national conference titled ‘Improving Services: Co-occurring Substance Abuse and Mental Health Disorders, held in November 1995’ is a report of the conference and a proposed national strategy based on the articles presented at the conference. This document aims to provide as much information about the National Strategy as possible, organized around four main goals. These include background information, best treatment and prevention practices, training and education, and financing and managed care.


M. Ridgely, Susan, H. Goldman, M. Willenbring, and M. Ridgely. (1998). Organizational and institutional issues concerning the care of people with dual diagnoses: Barriers to care. Readings in the Dual Diagnosis setting. In the Proceedings of the IAPSRS, 399-414.

Among the frustrations of managing the dual disorders of chronic mental health and alcohol and drug abuse is that knowing what to do (by way of special programming) is insufficient to address the problem. The systems problems are at least as intractable as the chronic illness themselves. Organizing and financing care of patients with comorbidities are complicated. At issues are how we administer mental health and alcohol and drug treatment and finance that care. In addition to creating problems inherent in serving persons with multiple disabilities, different administrations and funding pools have been selected for their political expediency, visibility and administrative efficiency.


Local governments and programs are limited by arbitrary service divisions and categorical boundaries at the State level, which hinder joint projects or creatively managing patients from across service boundaries. We become more likely to reinforce overutilization of hospital services and emergency services if patients cannot adapt to services’ organizational structure. This article discusses obstacles to health care organization and funding (categorical and third party financing, including the particular danger of diagnosis-related group limitations). It is concerned with the formulation of strategies for enhancing appropriate treatments. (author)


Sciacca, K., & Thompson, C.M. (1996). It is the responsibility of the United States Government to develop and implement programs for Dual Diagnosis: Mental Illness, Drug Addiction, and Alcoholism. Medical Management Journal. 23, 3.

The authors present one of the first examples of an integrated mental health and substance abuse program development model utilized in the Jackson and Hillsdale counties of Michigan in 1993. In addition to incorporating elements from both systems, the program offered a comprehensive program. This collaboration included the formulation and integration of ‘philosophical perspectives, redefining roles, and a treatment approach that incorporated a holistic approach. This article discusses topics such as planning for integration, recruitment and training of staff members, implementation of programs, definitions of dual/multiple disorders, and program philosophy and treatment approaches.

Treatment Related and Treatment Efficacy Studies

Clark, R. (1996). Providing Family Support to Persons with Dual Disorders. Recent Research and Clinical Implications of Dual Diagnosis of Major Mental Illness and Substance Abuse. The new directions in mental health services. 70. 65-78. An article in a journal discusses the critical role that families play in impacting the lives of individuals with dual disorders. It explains that although there is a high importance placed on providing support services and rehabilitation to persons with severe mental health, even those able to live independent lives, this cannot be achieved at the expense of families and friends providing informal social support.

The article detailed how optimal functioning occurs through a supportive system, not independently, and stresses the importance of effective interdependence. Family support is discussed in terms of its benefits and burdens, factors that influence family support, treatment and family relationships, and clinical implications of family support. Among the ten recommendations of the authors are that clinicians and policymakers should include services designed to build family relationships and maintain positive family relationships as part of the treatment strategy.


Drake, R.E., Mueser, K.T., Clark, R.E., & Wallach, M.A. (1996). A study of the course, treatment, and outcome of substance abuse among individuals with severe mental health. American Journal of Orthopsychiatry, 66, 42? 51. This chapter summarizes findings concerning the longitudinal course of dual disorders, discusses the current trend towards integrative treatment programs, and examines the evidence for the efficacy of integrated treatment. The guide includes a review of the evidence for integrated treatment, with over 30 studies proving effective, but most of these struggle with methodological flaws. It also includes a discussion of policy implications for integrated treatment.

Drake, R. and Maueser, K. (1996). Alcohol-Use Disorder and Severe Mental health. Alcohol Health and Research World. 20. 2. 87-93.

It is common for people with schizophrenia or bipolar disorder to have alcohol misuse disorders, which can worsen their mental, physical, and social problems. Therefore, it is critical to thoroughly assess patients with severe mental health for alcohol and drug abuse to improve detection of alcohol-related problems, establish appropriate AUD diagnoses, and develop appropriate treatment plans. Recent studies have shown that integrated treatment approaches that combine AUD and mental health treatments may lead to the best outcomes for these clients. (author)


Drake, R.E., Bartels, S.J., Teague, G.B., Noordsy, D.L., & Clark, R.E. (1993). Substance Abuse Treatment in Severely Mentally Ill Patients. Journal of Nervous and Mental Disease, 181. 606-611. These principles were identified and clarified in this paper using current clinical research regarding substance abuse treatment among severely mentally ill patients. 13 NIMH-funded studies on experimental treatments for young people with serious mental health and substance dependence are reviewed in published clinical research studies. Janssen Pharmaceutical. (1997). Addiction and mental illnesses require a new vision of treatment. Mental Health Issues Today. 2.

In this newsletter article, the author discusses how current treatment systems need to be coherent with co-occurring intellectual and addiction disorders and how new approaches need to be developed for delivering such treatment. In addition, the article discusses the characteristics of people with co-occurring illnesses, the opinions of experts in behavioral health in the federal and state government, and innovative public sector treatment models and complications with the pharmacy component of care. A national council of co-occurring disorders experts drafted recommendations for the federal agency that funds and oversees mental health and substance abuse services in 1995-1996. (author)

Jerrell, J.M. & Ridgely, M.S. (1995). This study shows that three approaches can serve severe mental health and substance abuse disorders. Journal of Nervous and Mental Disease. 183, 566-576.


This study is designed to explore and rate the relative effectiveness of three intervention models in treating individuals with severe mental health and addiction disorders. The three models are behavioral skills training, intensive case management, and 12-step recovery. Over 24 months, 132 dual-diagnosis clients were followed to assess symptoms of psychiatric and substance abuse problems. Compared to clients in the Twelve Step approach, clients in the behavioral skills group showed the greatest improvements in psychosocial functioning and symptomatology. Several positive and important differences were found between the case management intervention and the Twelve Step intervention. Still, the case management intervention had the lowest mortality rate of the two interventions.

Webb, J. (1996). Psychiatric Hospitals Still in the Chemical Dependency Business: Comorbidity of Chemical Dependency with Psychiatric Symptoms. Report: 33 pages.


This report offers a comprehensive study of dual disorders and mental health. This study offers comprehensive information concerning the prevalence, characteristics, and treatment of dual disorders and mental illness. The book includes selected comparative analyses of the twelve-step and mental health models and presents the national council on alcoholism and drug dependency’s definition of alcoholism. A summary of an article that presents anxiety disorders, personality disorders, mental health, and chemical dependency. Also identified are signs and symptoms of intoxication, chemically induced toxic syndromes; risk factors for substance abuse; and addiction treatment.

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