SECTION I: Background

SECTION I, Background In an era of declining resources and increasing health care needs, the problems of people with co-occurring mental health and substance abuse disorders assume special importance. This section examines the scope of the problem, some historic barriers to providing comprehensive care for these individuals, and signs that progress is being made.

The Scope of the Problem Co-occurring mental health and substance abuse disorders are a significant problem in the United States today. Estimates suggest that up to 10 million people in this country have a combination of at least one co-occurring mental health and substance-related disorder in any given year. Three million individuals with co-occurring mental health and substance abuse disorders have at least three disorders, and one million people have four or more disorders (SAMHSA NAC, 1997).

But numbers only begin to tell the story. Individuals with co-occurring disorders tend to be more symptomatic; to have multiple health and social problems, and to require more costly care. Many are in jails and prisons, where they may receive treatment that is inappropriate, if they receive any treatment at all. Others end up homeless. Of the estimated 7.2 million adults between the ages of 18 and 54 with co-occurring disorders who are living in households, a majority receive no treatment at all, not even in the primary health care sector (SAMHSA NAC, 1997).

The Importance of the Population Given the immense human and economic toll that co-occurring disorders exact, meeting participants agreed that individuals with co-occurring mental health and substance abuse disorders are a high priority population. Their needs should be addressed not only by the mental health and substance abuse systems, but by the primary health care system, as well.

However, the term “co-occurring disorders” does not connote a single problem with a simple solution. People with co-occurring disorders are a heterogeneous group with multiple medical and social problems. As noted above, they are at risk for incarceration and homelessness, and significant numbers are HIV-positive. Post-traumatic stress disorder (PTSD), often from childhood physical and/or sexual abuse, also tends to be a problem for this group, participants noted.

?For a number of reasons that are outlined below, treatment for people with co-occurring disorders is problematic, at best. As a result, many of these individuals cycle in and out of costly and often inappropriate treatment settings, such as hospital emergency rooms. Some are being inappropriately treated in other settings, such as jails or prisons. Still others end up homeless and may be receiving no treatment at all.

In general, outcomes for physical health, substance abuse and mental health disorders are worse for individuals with co-morbid conditions. Meeting participants agreed that this is a population with whom no system is completely successful at this time.

Barriers to Providing Care Historically, there have been a number of barriers to providing effective treatment for people with co-occurring substance abuse and mental health disorders. To begin with, there is no single locus of responsibility for people with co-occurring disorders. The mental health and substance abuse systems operate independently from one another and from the primary health care system.

The separation between the substance abuse and mental health systems is driven in large part by the fact that each system has its own treatment philosophies, administrative structures, and funding mechanisms. For example, substance abuse providers may treat mental health symptoms as part of addictive disease, rather than as an independent disorder. Typically, each system collects its own unique data; funding streams are usually separate. In addition, licensure and certification mechanisms reflect different training and experience requirements.

This level of separation between systems means that neither consumers nor providers move easily among service settings. Substance abuse and mental health providers, in particular, are not customarily trained in each other?s disciplines, nor is the issue of cross-training adequately addressed in medical schools. There is a general lack of knowledge about what the other system does, and often there is a lack of trust born in part of the fear that one system will either subsume the other in any collaborative efforts or fail to fulfill its treatment commitments.

Further, there is still a great deal of stigma that surrounds both disorders, including among the people who have them. As one meeting participant noted, individuals with a mental health disorder are reluctant to be labeled with a substance abuse disorder, and vice versa.

Even when the two systems agree to work together, there are often no shared assessment tools to help determine the exact nature and extent of mental health and substance abuse disorders. This makes diagnosis and treatment planning especially challenging, as providers face the complex task of discerning the meaning of multiple symptoms independent of one another, often arriving at divergent diagnoses of similar presenting symptoms.

Setting the Stage for Dialogue Despite their differences, the mental health and substance abuse communities have taken a number of important steps in recent years to find common ground. Recognizing the need to work together on behalf of individuals with co-occurring disorders, they have forged some innovative initiatives at the Federal, State, and local levels.

?In 1995, SAMHSA convened a national conference on co-occurring disorders with more than 140 experts and Federal staff. The report resulting from the conference recommended a national strategy in the areas of data and research, best prevention and treatment practices, education and training, and financing and managed care (SAMHSA NAC, 1997). That meeting was a catalyst for a number of subsequent actions on the part of Federal, State, and local agencies; public and private providers; payers; program administrators; and policy makers.

As part of its goal to empower change at the State and local level, SAMHSA and two of its centers ? the Center for Mental Health Services (CMHS) and the Center for Substance Abuse Treatment (CSAT) ? supported the June 1998 meeting of State mental health commissioners and alcohol and drug abuse directors on which this report is based. Their effort was co-sponsored and facilitated by the directors? two national associations, the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD).

?In addition to Federal and State-level meetings addressing the issue of co-occurring disorders, an extensive body of literature has been developed in recent years. Prior to their meeting in June, the State mental health commissioners and alcohol and drug abuse directors reviewed a comprehensive set of resource materials that included technical assistance documents, epidemiological studies, service delivery design reports, and treatment efficacy studies (see the “References” section at the end of this report for a complete list of available materials). In reviewing this literature, which represents the state- of- the- art in knowledge about co-occurring disorders, participants came to the meeting with a thorough understanding of the issues and a common context for their discussions.

Finally, to set the stage for dialogue at the June 1998 meeting, the State alcohol and drug abuse directors and mental health commissioners heard from a panel of experts who addressed the extent and nature of the problem of co- occurring disorders and highlighted some emerging treatment options. Their presentations are summarized in brief below.

The Interactive Nature of Co- occurring Disorders. Mental illness and substance abuse can co- occur by chance or by the interactive nature of the conditions, noted Mark Schuckit, M.D., Professor of Psychiatry at the University of California, San Diego, and Director of the Alcohol and Drug Treatment Program at the San Diego Veterans Affairs Hospital. He outlined three ways in which mental health and substance abuse disorders may relate to one another: 1) psychiatric disorders may occur independently of substance abuse disorders; 2) psychiatric disorders, such as schizophrenia and anti-social personality disorder, may place individuals at greater risk for substance abuse; and 3) temporary psychiatric syndromes may be induced by drug abuse intoxication or withdrawal.

Individuals with psychiatric disorders may use alcohol or drugs to self- medicate their mental health symptoms, Dr. Schuckit noted, but the reason why the disorders co- occur may be less important than the need to screen for their overlap. Individuals with psychiatric disorders should be screened for substance abuse disorders, and vice versa, he urged the group. Treatment will be guided by the specific conditions the individual has; i.e., the clinician may need to treat psychotic symptoms before a substance abuse problem can be addressed.

The Need for Comprehensive and Individualized Services. Co-occurring disorders are chronic and complex, reflecting multiple medical and social problems and involving numerous service delivery systems, according to Bert Pepper, M.D., Executive Director of The Information Exchange in New York City. Successful and cost-effective treatment for these complicated conditions must be comprehensive, integrated, and individually tailored to reflect the consumer?s changing needs and motivation.

Because people with multiple diagnoses tend to fall through the cracks of uncoordinated systems of care, Dr. Pepper stressed the need to integrate services and coordinate funding at the local service delivery level. He noted, however, that integration is a matter of degree?because of their multiple and complex needs, individuals with co-occurring disorders may require different levels of help to coordinate specialty care, such as treatment for HIV.

The Emergence of Innovative Service Delivery Techniques. Innovative treatment approaches for co- occurring disorders are being developed in both substance abuse programs and in mental health programs, according to the final two presenters at the meeting. Jerome Carroll, Ph.D., Vice President for Clinical Operations at Project Return, a modified therapeutic community (TC) for people with substance abuse disorders in New York City, described how his program used a small state grant to add mental health staff. This allowed staff to enhance services to residents with co- occurring mental health disorders.

Individuals with psychiatric disorders were fully integrated into the TC program, which sets positive expectations for residents and promotes their independence, Dr. Carroll said. Though such a program would not be appropriate for individuals in acute psychiatric crisis, the consumers with co- occurring disorders involved in Project Return have shown positive outcomes. These include decreased alcohol and drug use and homelessness and increased employment, Dr. Carroll reported.

Robin Clarke, Ph.D., Associate Professor of Family and Community Medicine at Dartmouth Medical School, reported on the results of a New Hampshire study that featured the addition of a substance abuse specialist to an assertive community treatment (ACT) team for people with serious mental illnesses. Individuals received their care at community mental health centers, and treatment included the stages of substance abuse recovery ? engagement, persuasion, active treatment, and relapse prevention.

Results from a three-year follow-up reveal a decline in arrests, incarceration, and costs associated with family caregiving for the study group. Recovery for people with severe impairments is slow and potentially expensive at the outset, Dr. Clarke, said, but the positive impact on personal and societal costs is significant.

The Need for a Common Language To reach any type of consensus on treatment and services for people with co- occurring disorders, the substance abuse and mental health communities must speak the same language. As has been recently pointed out by a number of observers in both mental health and substance abuse fields, there are significant opportunities for language confusion both within and between the two treatment communities. The phrases “severe mental illness”, “serious mental illness” and “chronic mental illness” are often used interchangeably within the mental health field, although they convey different meanings and connotations. “Substance use disorder” and “substance abuse” present similar confusion with the alcohol and drug field. Phrases such as “dual diagnosis”, “co-occurring disorders”, “mental illness and chemical abuse (MICA)”, “dual disorders” and “co-morbidity” – all apparently intended to describe the same clinical phenomenon – offer myriad opportunities for confusion between the two fields. Of particular importance to mental health and alcohol and drug service providers is defining specific co-occurring population groups to be served.

Modifying a model originally developed in the State of New York, the group formulated a conceptual framework for discussing symptom multiplicity and severity, locus of care, and level of service coordination needed among the mental health, substance abuse, and primary health care systems which effectively responds to this basic definitional question. This framework is outlined in the next section.

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