Experts Identify Problems, Examine Solutions (Part 1)
By Rebecca A. Clay
Four million American adults suffer from both serious substance abuse disorders and
serious mental illness. Yet more than half of these individuals with co-occurring disorders
receive neither specialty substance abuse nor mental health treatment, according to
a new SAMHSA report.
SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W., welcomed
conference participants by video telecast. "Individuals with co-occurring disorders
should be the expectation, not the exception, in the substance abuse treatment
and mental health service systems," he said.
SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W., unveiled the report (see
4 Million Have Co-Occurring Serious Mental Illness, Substance Abuse) at a 3-day conference in June, "Complexities of Co-Occurring Conditions:
Harnessing Services Research to Improve Care for Mental, Substance Use, and Medical/Physical
Disorders" held in Washington, DC.
Sponsored by SAMHSA, the National Institute on Drug Abuse (NIDA), the National Institute
of Mental Health (NIMH), the National Institute on Alcohol Abuse and Alcoholism (NIAAA),
and the Agency for Healthcare Research and Quality (AHRQ), the event attracted hundreds
of researchers, prevention specialists, treatment providers, service administrators,
policymakers, and consumers. Participants came together in 4 plenary sessions, 25 concurrent
panels, and 66 poster presentations to explore ways to better meet the needs of people
with co-occurring conditions.
Helen Burstin, M.D., M.P.H., Director of the Center for Primary
Care, Prevention, and Clinical Partnerships at AHRQ, and Jack B. Stein, Ph.D.,
Chief of the Services Research Branch at NIDA, welcomed participants to the conference.
Goals were to encourage collaboration, explore innovative theoretical models and
cutting-edge research, and set a research agenda for the future.
"Individuals with co-occurring disorders should be the expectation, not the
exception, in the substance abuse treatment and mental health service systems,"
Mr. Curie told conference participants via video. "Unfortunately, there continue
to be many barriers to appropriate treatment and support services. Clearly our systems
of services must continue to evolve to reflect the growing evidence base that promotes
integrated treatment and supportive services. Both disorders must be addressed as primary
illnesses and treated as such."
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Barriers to Integration of Care
- Separate and uncoordinated systems
- Separate funding streams
- Lack of cross-training
- Philosophical differences
- Conflicting regulations
- Lack of research.
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A Complex Interplay
NIMH Deputy Director Richard Nakamura, Ph.D., opened the conference by describing
the prevalence of substance abuse and mental health disorders.
Citing World Health Organization figures, he noted that mental and behavioral disorders
such as depression, substance and alcohol use, self-inflicted injury and death, and
similar problems play an enormous role in the global burden of disease. "Substance
abuse and mental illnesses account for almost 40 percent of the disability in the developed
world," he said.
To help conceptualize the complexities of co-occurring conditions, Richard Ries,
M.D., a professor of psychiatry at the University of Washington Medical School in Seattle,
WA, described a matrix now widely used by states (see illustration below).
Focusing on mental illness and substance abuse, the matrix's four quadrants help
users conceptualize levels of severity and the primary focus of treatment for co-occurring
disorders. It also shows how the mental health and substance abuse systems may work
together to address the needs of this population. For example, treatment for those
with high-severity addiction and low-severity mental illness could be based in the
addiction system with consultation from mental health. Those with combined high severities
of both disorders would need specialized treatment with cross-trained staff, expert
on both conditions.
The four-quadrant model provides a conceptual framework for
understanding the range of co-occurring conditions and the level of coordination
that service systems need to address them.
Co-occurring conditions such as HIV/AIDS, hepatitis, or any of the other physical
ailments that often accompany mental illness and substance abuse compound the problem.
"As a primary care physician seeing patients who routinely have a half-dozen
or more diagnoses, I'm confused by terminology like 'dual diagnosis' and 'comorbidity,'
" said Richard Saitz, M.D., M.P.H., an associate professor of medicine and epidemiology
at the Boston University Schools of Medicine and Public Health. The former implies
there are only two diagnoses, he explained, while the latter implies that one diagnosis
Urging conference participants to expand their conceptual model to include medical
conditions, Dr. Saitz noted that people with psychotic disorders, substance use disorders,
or both have higher rates of medical problems like heart disease and asthma than those
without mental health conditions. They're also less likely to get optimal care or adhere
to treatment regimens.
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In the Trenches
How does this complexity play out in real life? Joan Zweben, Ph.D., Executive Director
of the 14th Street Clinic and East Bay Community Recovery Project in Berkeley, CA,
provided an addiction treatment provider's frontline perspective.
Joan Zweben, Ph.D. (top right), and Renata Henry, M.Ed. (bottom
"A unified funding source
makes it much easier to provide state-of-the-art treatment," said Dr. Zweben.
"It is much more difficult to achieve the same level of services with fragmented
Although the clinic does its best to integrate psychiatric and medical care into
its services, it faces several barriers. Graduate training programs, for example, typically
don't include substance abuse as part of their core curricula. As a result, said Dr.
Zweben, "there's a dearth of cross-trained people." What's needed, she said,
is a way to cross-train professionals and to ensure that staff members of substance
abuse treatment programs are developing their skills continuously.
Conflicting licensing, site certification, and other regulations also add to the
difficulty of integrating substance abuse, psychiatric, and medical care. While substance
abuse treatment programs usually discourage participants from engaging in sexual activity,
for example, community care licensing rules prohibit such interference in private lives.
Another barrier is the lack of what Dr. Zweben called a "universal chart,"
a comprehensive medical record that would cover both substance abuse and mental health
treatment. In addition to reducing duplication in data entry, such a chart could also
help policymakers keep track of what's happening to those with co-occurring conditions.
« See AlsoPrevious
Part 2 »
Part 3 »
See AlsoConference Panels:
Improving Outcomes »
Housing and Treatment »
Diffusion of Evidence-Based Care Practices »
Depression and Illness: Coordinating Care »
See AlsoComplexities of Co-Occurring Conditions Conference:
4 Million Have Co-Occurring Serious Mental
Illness, Substance Abuse »
Center for Excellence »
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