Appendix B

Resource Materials


JUNE 16-17, 1998 WASHINGTON, DC?


I.? Annotated Bibliography:

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

II. Center for Mental Health Services Technical Assistance documents:

Center for Mental Health Services (1998). Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice Guideline, Workforce Competencies, and Training Curricula. Report of the Center for Mental Health Services Managed Care Initiative: Clinical Standards and Workforce Competencies Project. (CMHS Publication). Rockville, MD. Parts 1-4 (Part 5 “Training Curricula” not included in materials provided in briefing packet. Full copy available onsite).

Center for Mental Health Services (1997). Addressing the Needs of Homeless Persons with Co-Occurring Mental Illnesses and Substance Use Disorders. (SAMHSA Publication) Rockville, MD.

Center for Mental Health Services (1996). Implementing Interventions for Homeless Individuals with Co-Occurring Mental Health and Substance Use Disorders. (SAMHSA Publication) Rockville, MD.

Center for Mental Health Services (1996). Preventing Homelessness Among People with Serious Mental Illnesses. (Draft SAMHSA Publication), Rockville, MD.

Epidemiological/descriptive studies of co-occurring disorders:

Drake, R.E., Alterman, A.I., & Rosenberg, S.R. (1993). Detection of Substance Use Disorders in Severely Mental Ill Patients. Community Mental Health Journal, 29, 175-192.

This paper reviews issues related to detecting alcohol and other drug problems in severely mentally ill patients. Reviews current knowledge in fields, suggest clinical guidelines, and indicates uses of future research. Proposes separate detection strategies for alcohol and illicit drug use.

Kessler, R.C., Nelson, C.B., McGonagle, K.A., Edlund, M.J., Frank, R.G., & Leaf, P.J. (1996). The Epidemiology of Co-Occurring Addictive and Mental Disorders:

Implications of Prevention and Service Utilization. American Journal of Orthopsychiatry, 66, 1, 17-31.

Presents results from the National Comorbidity Survey (NCS). Results indicated that 51 percent of those with a lifetime addictive disorder also had a lifetime mental disorder, which is a higher prevalence rate than that found in the NIHM Epidemiological Catchment Area Study. Additionally, the NCS found that the majority of those with co-occurrence had at least one mental disorder occur at an earlier age than their first addictive disorder. In general, co-occurrence is highly prevalent in the general population and is associated with a significantly increased probability of treatment.

National GAINS Center. (1997). The Prevalence of Co-Occurring Mental and Substance Abuse Disorders in the Criminal Justice System. Delmar, NY,

The fact sheet presents details on the explosive growth in co-occurring mental and substance abuse disorders in the criminal justice system over the past decade. It explains 3 percent of the total U.S. adult population is currently under some form of correctional supervision, discusses how the growing correction population includes an increasing number of individuals with special treatment needs, and reports on estimates that indicate that more than half of the people in the criminal justice system have diagnosable, serious mental illness or substance abuse disorders. This fact sheet addresses the percentage of jail detainees and persons in jail with mental illness or substance abuse disorder, or both; comments on the prevalence estimates of serious mental illness among the growing number of people under community supervision; and expresses concern for the co-morbidity of serious mental illness and substance abuse or dependence among the general population.

Schuckit, M.A., & Hesselbrock, V. (1994). Alcohol Dependence and Anxiety Disorders: What is the relationship? American Journal of Psychiatry, 151, 1723-1734.

This paper critically reviews literature regarding the relationship between lifelong DSM-III-R anxiety disorders and alcohol dependence. The paper notes that the interaction between alcohol use and anxiety disorders is complex. Findings based on available data do not prove a close relationship between lifelong anxiety disorders and alcohol dependence. Prospective studies of children of alcoholics and individuals from the general population do not indicate a high rate of anxiety disorders preceding alcohol dependence. Concludes that high rates of comorbidity in some studies reflect a mixture of true anxiety disorders among alcoholics at a rate equal to or slightly higher than the general population, along with temporary substance-induced anxiety syndromes.

Service Delivery Design issues:

Minkoff, K. (1997). Integration of Addiction and Psychiatric Services. Managed Mental Health Care in the Public Sector. Harwood Academic Publishers, Amsterdam. 233-245.

This chapter discusses the importance of integrated programming of psychiatric and addiction services in order to respond competitively to the demands of managed care. Advantages and disadvantages of integrated services are discussed, followed by an argument in favor of integrated service delivery. A step-by-step process for implementation is presented, focusing on organizational philosophy and mission, agency structure, clinical program, and staff development.

Minkoff, K. (1991). Program Components of a Comprehensive Integrated Care System for Serious Mentally Ill Patients with Substance Disorders. New Directions for Mental Health Services, 30, 13-27.

This chapter describes an integrated theoretical framework for understanding dual diagnosis and uses this framework to develop a model system of care.

NASADAD (1997). Preliminary Information on Services to Individual with Co-Existing Substance Abuse and Mental Health Disorders. (NASADAD report submitted to CSAT).

Summarizes results of a NASADAD survey of State Alcohol and other Drug Agencies and State Mental Health Authorities. Provides State-level analysis of the organization, design, delivery, and financing of services for co-existing disorders. Includes State-level definitions of co-occurring disorders.

NASADAD and NASMHPD (1998). Substance Abuse and Mental Health Services Linkages with Primary Care: Analysis of State Surveys and case Studies. (Joint NASADAD and NASMOHD draft report to HRSA).

Examines policies and procedures States have developed and implemented to promote linkage among mental health, substance abuse, and primary health care services. Identifies the structural barriers which interfere with linkage efforts, as well as the methods States have used to overcome such barriers. Additionally, through case studies, the report examines innovative practices three states have used to promote linkages.

National Health Policy Forum. (1997). Dual Diagnosis: The Challenge of Serving People with Concurrent Mental Illness and Substance Abuse Problems. Issue Brief, 718.

This report summarizes a roundtable discussion held on April 14, 1998 in Washington, DC on the prevalence of co-occurring mental illness and substance abuse problems or “dual diagnosis”. It explains how this population seems to have emerged as a consequence of deinstitutionalization, points out that this population is prone to homelessness and/or incarceration, and addresses considerable barriers to effective intervention. It presents data from major surveys; comments on trends in comorbibity, causality, and relapse; illustrates the proximate risk factors of dual diagnosis, homelessness, and crime; notes several factors, contributing to increased comorbidity; and addresses issues in the improvement of treatment. This report also includes strategies suggested by the SAMHSA National Advisory Council to improve prevention, treatment. and rehabilitation services for the several million individuals with, or at risk of developing, co-occurring substance-related mental health disorders.

Osher, F. (1996). A Vision for the Future: Toward A Service System Responsive to those With Co-Occurring Addictive and Mental Disorders. American Journal of Orthopsychiatry, 66, 1, 71-76.

Identified by providers, family member, administrators, and consumers as an issue creating frustration, high costs, and a profoundly negative impact on quality of life, co-occurring addictive and mental disorders cry out for creative and alternative clinical responses. With empirical research and clinical experience supporting the effectiveness of integrated addictive and mental health services. A change toward integrated systems of care is likely to benefit the mental health and addiction treatment needs of all people, not just those with co-occurring disorders. (author)

SAMHSA National Advisory Council. (1997). Improving Services for Individuals at Risk of, or with, Co-Occurring Substance-Related and Mental Health Disorders. Rockville. MD.

Conference report and proposed National Strategy based on the National Conference, “Improving Services: Co-occurring Substance Abuse and Mental Health Disorders” held in November, 1995. Presents background information, as well as National Strategy organized around 4 main goals relating to data and research; best prevention and treatment practices; training and education; and financing and managed care.

Ridgely, M., Susan, Goldman, H., Willenbring, M. (1998). Barriers to Care of Persons with Dual Diagnosis: Organization and Financing Issues. Reading in Dual Diagnosis. IAPSRS, Columbia, MD, 399-414.

Among the frustrations of managing the dual disorders of chronic mental illness and alcohol and drug abuse is the fact 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 comorbities is complicated. At issues are the ways in which we administer mental health and alcohol and drug treatment as well as finance that care. Separate administrative divisions and funding pools, while appropriate for political expediency, visibility, administrative efficiency, have compounded the problems inherent in serving persons with multiple disabilities. Arbitrary service divisions and categorical boundaries at the State level prevent local governments and programs from organizing joint projects or creatively managing patients across service boundaries. When patients cannot adapt to the way services are organized, we risk reinforcing their overutilization of inpatient and emergency services, which are ineffective mechanisms for delivering the care these patients need. This article reviews the barriers in organization and financing of care (categoric and third party financing, including the special problem of diagnosis-related groups limitations) and proposes strategies to enhance the delivery of appropriate treatment. (author)

Sciacca, K., & Thompson, C.M. (1996). Program Development and Integrated Treatment Across Systems for Dual Diagnosis: Mental Illness, Drug Addiction, and Alcoholism (MIDAA). Journal of Mental Health Administration. 23, 3.

The authors discuss a model of program development that has integrated mental health and substance abuse systems in the Jackson-Hillsdale counties of Michigan in 1993. To offer a comprehensive plan, the program incorporated and integrated elements of both systems throughout the continuum of services. The collaboration involved a formulated and integrated philosophical perspective, redefined roles, and an integrated, treatment approach. The article discusses planning for integration, staff selection and training, program implementation, working definitions of those with dual/multiple disorders, and program philosophy and approach to treatment.

Treatment ?related and Treatment Efficacy studies:

Clark, R. (1996). Family Support for Persons with Dual Disorders. Dual Diagnosis of Major Mental Illness and Substance Abuse, Volume 2: Recent Research and Clinical Implications. New Directions for Mental Health Services. 70. 65-78.

This journal article discusses how families play a critical role in the lives of most persons with dual disorders. It explains that although community mental health and psychosocial rehabilitation programs place a high premium on helping persons with severe mental illness to live independently, independence cannot be achieved at the expense of informal social support from family and friends. This journal article explains that optimal functioning is not something that a person achieves independently but rather in the context of a supportive system, and stresses the importance of effective interdependence. It discusses various benefits and burdens of family support, factors that influence family support, treatment and family relationships, and clinical implications of family support. The authors note research findings involving this system of treatment and encourage clinicians and policy makers to incorporate services that strengthen family relationships.

Drake, R.E., Mueser, K.T., Clark, R.E., & Wallach, M.A. (1996). The Course, Treatment, and Outcome of Substance Disorders in Persons with Severe Mental Illness. American Journal of Orthopsychiatry, 66, 42 ? 51.

Reviews findings on the longitudinal course of dual disorders, describes the movement towards programs that integrate both types of treatment; and reviews evidence of the efficacy of integrated treatment (noting that there are over 30 studies of integrated treatment, most of which suffer from methodological weaknesses). Also includes discussion of policy implications.

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

Alcohol-use disorders (AUDs) commonly occur in people with other severe mental illnesses, such as schizophrenia or bipolar disorder; and can exacerbate their psychiatric, medical, and family problems. Therefore, to improve detection of alcohol-related problems, establish correct AUD diagnoses, and develop appropriate treatment plans, it is important to thoroughly assess patients with severe mental illness for alcohol and other drug abuse. Several recent studies have indicated that integrated treatment approaches that combine AUD and mental health interventions in comprehensive, long-term, and stagewise programs may be most effective for these clients. (author)

Drake, R.E., Bartels, S.J., Teague, G.B., Noordsy, D.L., & Clark, R.E. (1993). Treatment of Substance Abuse in Severely Mentally Ill Patients. Journal of Nervous and Mental Disease, 181. 606-611.

This paper identifies and clarifies emerging treatment principles from current clinical research related to the treatment of substance abuse among severely mentally ill patients. Surveys published clinical research reviews 13 demonstration projects on young adults with serious mental illness and substance problems funded by NIMH.

Janssen Pharmaceutical. (1997). Providing Coherent Treatment to those with Co-Occurring Addictive and Mental Disorders Requires New Vision. Mental Health Issues Today. 2.

This newsletter article discusses the current need to provide coherent treatment to those with co-occurring addictive and mental disorders and new approaches to this type of delivery system. It describes the characteristics of co-occurring illness population, opinions of federal and state behavioral health experts related to existing barriers to care, highlights of innovative public sector treatment models, and complications associated with administering the pharmacy component of care. This newsletter article also includes recommendations drafted in 1995-1996 by a national council of co-occurring disorders experts to the federal body responsible for funding and overseeing substance abuse and mental health services. (author)

Jerrell, J.M. & Ridgely, M.S. (1995). Comparative Effectiveness of Three Approaches to Serving People with Severe Mental Illness and Substance Abuse Disorders. Journal of Nervous and Mental Disease. 183, 566-576.

This study examines the relative effectiveness of three intervention models (behavioral Skills training, intensive case management, and twelve step recovery) for treating individuals with severe mental illness and substance abuse disorders. Changes in psychosocial outcomes, and psychiatric and substance abuse symptomatology were assessed over 24-months in 132 dually diagnosed clients. Results indicated that clients in the behavioral skills group demonstrated the most positive and significant differences in the psychosocial functioning and symptomatology compared to the Twelve Step approach. However, the case management intervention also yielded several positive and important differences compared to the Twelve Step intervention.

Webb, J. (1996). Dual Disorders: The Co-Morbibity of Chemical Dependency and Psychiatric Illness or, Why Psychiatric Hospital are Still in the Chemical Dependency Business. Report: 33 pages.

This report offers comprehensive information on the prevalence, nature and treatment of dual disorders. It includes selected comparisons of twelve steps and mental health models; presents a definition of alcoholism by the National Council on Alcoholism and Drug Dependency, Inc.; notes prevalence data on morbidity, comorbidity, anxiety disorders, personality disorders, psychotic disorders, chemical dependency; and lists symptoms of a number of transient and persistent syndromes. Characteristic signs of intoxication states, chemically-induced toxic syndromes, and hazards in dual diagnosis recovery are also noted.

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