Section I: The Background

Section I: Introduction to Mental Health Issues The consequences of co-occurring mental health and substance abuse disorders assume increased importance during this time when resources are diminishing and health care needs are increasing. A number of aspects are discussed, including how big the problem is, some historical obstacles to comprehensive care for these individuals, and signs of progress.

People experiencing co-occurring substance abuse and mental health disorders are distinctive, so is their service systems through which they are to receive care. The creation of a framework aims to influence and inform the delivery of collaborative and integrated practices in delivering co-occurring mental health illnesses and substance abuse services. This framework is designed for children, young people, and adults. Ensuring that this framework is implemented lies with clinical leaders, government officials, and policymakers in the health, social, and educative sectors.

It is essential to define what co-occurring disorders are and what they entail. A person is diagnosed with co-occurring disorders when they experience mental health illnesses and substance abuse. Mental health disorders include:

• Bipolar disorder
• Depression
• Dysthymia
• Panic disorder
• Post-traumatic stress disorder
• Social anxiety
• Schizoaffective disorder and more

Substance abuse disorder includes drug/alcohol abuse and drug/alcohol dependence. 

This segment examines the Scope of the problem, some historical barriers to providing comprehensive care for these individuals, and signs that progress is being made. 

The Scope of the Problem Substance abuse and mental health problems often co-occur in the United States. It's estimated that up to 10 million Americans experience a mental disorder and substance use disorder at the same time each year. The National Institute for Mental Health reports that three million people with substance abuse and mental health disorders suffer from three disorders, and one million from four or more. (SAMHSA National Addiction Center, 1997).

But statistics only tell part of the story. The symptoms of co-occurring disorders are generally more severe, and they require more intensive medical attention and financial support. These people are often in jails or prisons, where they might receive inappropriate treatment if at all. Others become homeless. Approximately 7.2 million adults with co-occurring disorders do not receive any mental health treatment at all, including primary care, according to SAMHSA National Addiction Center.

The Population Importance Because co-occurring mental health and substance use disorders exact a tremendous human and economic toll, meeting participants agreed that this population should be a high priority. The mental health and substance abuse systems should not only take care of their needs, but also the primary health care system.

Although the term “co-occurring disorders” implies that there is an underlying problem, there is no simple solution to it.

 Multiple mental health medical and social issues affect people with co-occurring disorders. Additionally, they are at risk for homelessness and incarceration, and a significant number are HIV-positive. In addition to PTSD, often a result of childhood abuse, participants noted Post-Traumatic Stress Disorder as another issue.

Mental health Co-occurring disorders cause treatment to be complex, for a variety of reasons which are outlined below. These individuals are thus frequently treated at expensive and ineffective settings, such as hospital ERs. They are being mistreated in jails and prisons, and some are being denied medical care. Those who become homeless may not receive any treatment.

A person with co-morbid conditions is more likely to have poorer outcomes in terms of physical health, substance abuse, and mental health disorders. During the meeting, participants agree that there is no completely successful system for this population at present.

Co-occurring mental health and substance abuse disorders can sometimes be challenging to diagnose. The symptoms of substance abuse disorders tend to mask that of mental health disorders, and that of mental health disorders tends to hide that of substance abuse disorders. Individuals with mental health illnesses do not address their substance abuse issues because they believe it is not relevant to their problem.

Constraints to Providing Care The provision of effective treatment for individuals with co-occurring addiction and mental health has been hindered in the past by a number of provider barriers. First of all, people with co-occurring disorders have no single point of accountability. Substance abuse and mental health services are autonomous of primary health care.

The distinct treatment models, administrative structures, and funding mechanisms of the substance abuse and mental health systems contribute significantly to their separation.

 Mental health conditions may be diagnosed as disorders or as a part of addictions by substance abuse treatment providers. System-specific data are usually collected, and funding streams differ. Additionally, the training and experience requirements for licensure and certification vary.

As a result of this separation, neither service providers nor consumers are able to easily switch between service settings. Unlike other health care providers, substance abuse specialists and mental health professionals are not commonly trained in each others' fields, nor is the requirement to learn from one another sufficiently discussed in medical schools. There is a lack of understanding between systems, and they are often distrustful of one another out of concern that one may neglect its commitments or supplant the other.

Moreover, both disorders are still stigmatized, even by those who have them. One meeting participant stated that people with mental health are reluctant to be labelled with substance abuse disorders, and that the reverse is also true.

The assessment field often faces shortages, even when mental health and substance abuse disorders are assessed as a combined system. Although there are generally no standardised tools to measure the exact nature and extent of these disorders. In this context, diagnosis and treatment planning are particularly challenging, as providers must distinguish many symptoms independently from one another, resulting in a variety of divergent diagnoses.

Stage for Dialogue; Setting The Mental Health and Substance Abuse Communities Have Made Important Steps Toward Finding Common Ground In recent years, the mental health and drug abuse communities have made significant progress toward finding common ground. The collaboration initiated at the state, regional, and federal levels has fostered some innovative initiatives on behalf of people with co-occurring disorders.

In 1995, SAMHSA collaborated with Federal staff and more than 140 experts for a national conference on co-occurring disorders related to mental health. An accompanying report recommended that a national strategy be implemented to address data gathering and research, interventions, public awareness-building, training, funding, and managed care (SAMHSA National Assessment Council, 1997). After that meeting, several actions were taken by government agencies and agencies of states and local governments, as well as the public and private sectors, administrators, and the policymaking community.

A major focus area of SAMHSA and its Centers is empowering change at the state and local levels. A joint meeting of mental health commissioners and substance abuse directors was sponsored by the Center for Mental Health Services and the Center for Substance Abuse Treatment in June 1998, on which this report is based. Two national mental health associations-NASMHPD and NASAAD-supported the initiative, which was jointly sponsored by and facilitated by those organizations.

The issue of co-occurring disorders has been addressed at Federal and State levels as well as in an extensive body of literature developed in the last few years.

 A comprehensive collection of resources, including technical assistance documents, epidemiological studies, service delivery design reports, and treatment efficacy studies, was reviewed by the state mental health commissioners and alcohol and drug abuse directors before their June meeting. A complete list of references can be found in the “References” section of this report. The participants attended the meeting with a thorough understanding of co-occurring disorders resulting from analysis of this literature, which represented the state-of-the-art for co-occurring disorders.

The State Alcohol and Drug Abuse Directors and the Mental Health Commissioners discussed co-occurring disorders during the June 1998 meeting in preparation for the June meeting. A panel of experts discussed some of the emerging treatment options. Following is a brief overview of their presentations.

A Study of The Interaction Between Co-Occurring Disorders. Mental health and substance abuse can occur together by accident or as a result of an interactive process, notes Professor Mark Schuckit, MD of Psychiatry at the University of California, San Diego.

Among the Various Ways Mental Illness and Substance Abuse Disorders Can Be Related, He Outlined the Following Three:

• Substance abuse disorders and mental health issues are not the only cause of psychiatric disorders
• Individuals with psychiatric disorders may be at greater risk for substance abuse, such as mental health issues, schizophrenia and antisocial personality disorder
• Intoxication or withdrawal from drugs can induce temporary psychiatric syndromes

Alcohol or drugs may be used by individuals with psychiatric disorders to self-medicate their symptoms, but the reason for their co-occurrence is less important than screening for the overlap, Dr. Schuckit noted. He urged the group to look for substance abuse disorders among those with psychiatric disorders or mental health issues. Clinical treatment must be individualized to fit the individual's unique conditions; for example, psychotic symptoms may need to be addressed prior to a substance abuse problem.

According to Dr Howard Padwa, PhD and his colleagues, there are some specific issues within the mental health system that hinder effective co-occurring disorders services. They include:

• Insufficient training concerning the treatment of co-occurring disorders: This research showed that many practitioners are uncomfortable discussing drug, mental health issues or alcohol issues with their patients despite their patients' frequency of substance abuse disorders. This issue can be addressed by the engagement of additional training for the clinicians. The research also reported that training opportunities are limited due to the pressure of managing a large caseload. For most centres, the emphasis is on productivity, not quality.
• Failure to sustain integrated service delivery by organizations hinders their ability to serve individuals with co-occurring disorders: Organizations are no longer provided with as much time and as were available in the past to treat patient's substance abuse conditions. Some Organizations go as far as not consulting with external experts in co-occurring treatment.
• Communication with substance abuse treatment providers is also tricky: Some organizations have rules that prevent clients from speaking with providers outside the program. This makes it difficult for providers to monitor their patients' progress in mental health andsubstance abuse treatment. This review also showed that many caseloads and time constraints make establishing consistent contact with substance abuse treatment service providers unfeasible. The providers also stated that confidentiality concerns and substance abuse treatment agency policies concerning patient information disclosure also frustrate efforts to coordinate care.
• Restrictions concerning billing and diagnostic criteria complicate the delivery of integrated care for individuals with co-occurring disorders: Practitioners stated that they have been experiencing difficulty documenting how interventions focused on substance abuse disorders are related to psychiatric treatment services and goals. In the case of billing, this is based on the assessment, which will primarily be anxiety, depression or any other mental health disorder.
• Limitations of the local substance abuse treatment make coordinated care challenging to provide: Many providers explained that the services by local substance abuse disorders systems are incomplete and fragmented. Others added that identifying available services and determining which programs are appropriate for their patients is time-consuming and cumbersome. Participants stated that program admission procedures aggravate this problem. Sometimes a patient has to wait for months before getting a slot into the program.

The high frequency of comorbidity between mental disorders and substance abuse disorders does not mean that one was caused by the other, even if one appeared first. Common risks factors are a significant pathway that can contribute to the comorbidity between mental illnesses and substance abuse disorders. Mental health illnesses and substance abuse disorders are caused by overlapping factors such as epigenetic and genetic vulnerabilities, environmental influences such as exposure to trauma or stress and issues with a similar area of the brain.

The Integrated Co-occurring treatment (ICT) is an integrated treatment approach. ICT focuses on delivering an intensive home-based method of service. The integrated treatment approach provides a core set of services to individuals experiencing co-occurring disorders of severe mental health illnesses and substance abuse. This method also provides services for the families caring for these individuals. ICT providers mainly work with young people from age (ages twelve to seventeen) exhibiting co-occurring mental health disorders and substance abuse disorders. ICT also provides an intervention that impacts the contextual factors affected by their co-occurring diseases. This means that ICT requires both youth and family participation. A parent or guardian needs to be involved in this intervention process.

Components of the ICT approach include:

• Integrated treatment approach
• Cultural mindfulness
• Elements that are grounded in prior empirical research
• Home-based intervention service delivery mechanism

The Integrated Co-occurring treatment approach has proven to improve young people's treatment outcomes and their families. The outcomes include:

• Reduced mental health disorder symptoms
• Reduced substance abuse disorder symptoms
• Improved family functioning
• Improved community functioning
• Decreased juvenile justice charges and placement
• Improved school functioning
• Reduced number of out of home placement

Services that Are Comprehensive and Personalized. In New York City, Bert Pepper, M.D., Executive Director of The Information Exchange, finds that co-occurring disorders and mental health mental health issues show a complex interplay of medical and social issues and are related to a number of service delivery mechanisms. The best, most cost-effective way to treat these complex conditions is to offer a comprehensive, integrated, and uniquely tailored approach that takes into account the changing needs and motivations of the consumer.

Dr. Pepper stressed the importance of integrating health services and coordinating funding on the local level in order to ensure that people with multiple diagnoses do not fall between the cracks of uncoordinated systems of care. He suggested, however, that integration is more of a matter of level than pure integration due to mental health issues and co-occurring disorders' multiple and complex needs. There is a wide range of help needed for coordination of specialty care, including HIV treatment.

Developing Innovative Service Delivery Techniques. According to the final two presenters at the meeting, both substance abuse programs and mental health programs are developing cutting-edge treatment approaches for co-occurring disorders. Jerome Carroll, Ph.D. believes that a state grant allowed Project Return, a modified residential treatment program (RTP) for individuals recovering from substance abuse disorders, to hire mental health staff. This enabled the program staff to improve services for residents with co-occurring mental disorders.

Dr. Carroll said that TC also integrated individuals with psychiatric disorders into the program, empowering them and promoting their independence. Individuals with acute psychiatric crises would not be appropriate for this program, but it has proven effective for people with co-occurring disorders. Dr. Carroll mentioned the decreases in alcohol and drug use and homelessness as well as an increase in employment.

Among those treated in an assertive community treatment team were patients suffering from serious mental disorders, as reported in a report written by Dr. Robin Clarke, associate professor of family and community medicine at Dartmouth Medical School. As part of the community mental health center treatment, attendees also participated in stages of recovery from substance addiction, including engagement, persuasion, active treatment, and relapse prevention.

The study found that arrests, imprisonment, and caregiver costs declined for the study group over three years. In the beginning, Dr. Clarke said, recovery is slow and costly for people with severe impairments, but will result in significant savings in personal and societal costs.

To deliver mental health successful service, companies must invest in innovative services instead of copying what their competitors are doing. What should you do first? Sometimes self-service applications and automatic call distribution systems may not have been targeted towards customers. The customer should always come first. 

See the operation from the viewpoint of the consumer; attempt to act like the customer. Studies on mental health tells any operation procedure or action should be judged on the following criterion: Should it benefit the consumer or improve the customer experience? If not, refrain from doing so. Applying this rule to all consumer interactions and associated procedures would fundamentally change how a company communicates with its clients, which is the bedrock of service innovation.

The Basic Requirement for a Common Language In order to start working on treatment and services for people who suffer from co-occurring disorders, there needs to be a common language between the mental illness and substance abuse communities. There are significant chances for language confusion within and between the mental health and substance abuse communities, as has been noted by several observers in both fields. It is common for mental illness professionals to interchangeably refer to severe mental illness, serious mental health and chronic mental illnesses, despite the fact that these terms have different connotations and meanings. Similarly, “substance abuse” and “substance use disorder” are confusing terms in the alcohol and drug field. There are many terms used in mental health and substance abuse disciplines that imply the same clinical phenomenon – including “dual diagnosis”, “co-occurring disorders”, “mental illness and chemical abuse (MICA)”, and “dual disorders”. The first step to providing treatment to people who co-occur with mental illness and alcohol and drugs is identifying co-occurring populations.

A Framework Approach Should be Based on Core Principles Which Include:

• Services ensure effective communication both within service users and agencies through locally agreed pathways and treatment protocols
• Services should enable easy access for individuals suffering from co-occurring disorder
• Services should ensure direct clinical responsibility for delivering effective treatment and care
• Services should ensure a competent, well trained, experienced and supervised workforce
• Services should have effective leadership and properly established governance and accountability systems to monitor the delivery of co-occurring disorders treatment services
• Services should integrate and operate within co-production and conservative social and health care principles
• Interventions should be delivered on time
• Services should be appropriate and accessible to the people and address people with protected characteristics
• Services should provide holistic, recovery-focused treatment and care matched to the participants' needs

The framework should highlight the broader principles of co-production and prudent social and health care to ensure that services are effective, empowering and efficient. Organizations should adopt a policy of “do no harm” and maximize the use of existing resources to provide the minimum level of intervention required.

In New York State, the group used a modified version of the model to formulate a conceptual model for understanding symptomatology, locus of care, and coordination levels between primary care and mental health systems, which significantly addressed this fundamental question. The next section outlines this framework. Contact us to know more about mental health problems.