Experts Identify Problems, Examine Solutions (Part 2)
An Integrated System
Overcoming those barriers is possible, however. Renata Henry, M.Ed., Director of
Delaware's Division of Substance Abuse and Mental Health, described her state's successful
model for treating individuals with co-occurring conditions.
Ms. Henry began by adding to the list
of barriers to integration.
State mental health and substance abuse systems are typically separate and uncoordinated,
she explained. Funding streams usually require single diagnoses, so that individuals
need a substance abuse-related diagnosis to get treatment from a substance abuse treatment
program and a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders:
Fourth Edition to get mental health treatment. The two workforces often have different
educational backgrounds and treatment philosophies. And there's not a lot of research
on evidence-based practices for treating co-occurring disorders.
Substance abuse is under-addressed despite its contribution
to the dynamic of co-occurring conditions, said H. Westley Clark, M.D., J.D., M.P.H.,
Director of SAMHSA's Center for Substance Abuse Treatment and Co-Lead of SAMHSA's
Priority Matrix Program. He added that the tendency to focus on those with the
most severe problems means an enormous population in critical need is being overlooked.
Faced with such obstacles, Delaware took action. With the state's substance abuse
and mental health divisions already integrated administratively, leaders committed
to improving services for individuals with co-occurring conditions. They blended funding
streams, and they developed a training program so that staff in the mental health,
substance abuse, homelessness, criminal justice, and health care systems are able to
treat people no matter what treatment "door" they enter.
More needs to happen to eliminate barriers, Ms. Henry said. Administrators need to
establish standards, initiate dialogues, disseminate information and tools, and remove
funding and regulatory barriers. The Federal Government should develop policies that
encourage integration, eliminate funding barriers, and improve dissemination of research.
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Researchers are already busy trying to determine what treatments work best. But conducting
research on co-occurring conditions requires investigators to ask new questions and
develop new ways of working, noted Constance Weisner, Dr.P.H., M.S.W., a professor
of psychiatry at the University of California and an investigator in the Division of
Research at Northern California Kaiser Permanente.
Constance Weisner, Dr.P.H., M.S.W. (top right), and Margarita
Alegria, Ph.D. (bottom left)
"We need to move away from the traditional paradigm of investigators setting
the research agenda alone and move toward developing questions in collaboration with
clinicians," she said, noting that health plan administrators, primary care providers,
accrediting bodies, policymakers, and others should be involved. She described a cyclical
process: a continuous loop of brainstorming questions, studying interventions, implementing
findings, and using the results to identify new questions.
Researchers also need to put more emphasis on studying the elements that influence
adoption of best practices, said
Dr. Weisner. Although a lot of research shows that integrated treatment is effective,
for instance, most clinical trials focus on homogeneous populations, which may not
represent the demographics of a particular treatment center or service provider accurately.
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Incentives for Quality
Financing is one of the real-life factors that affect the treatment of co-occurring
"Over the last 5 years, national attention on the financing of services for
co-occurring conditions has been growing," said Mady Chalk, Ph.D., Director of
the Division of Services Improvement at SAMHSA's Center for Substance Abuse Treatment
(CSAT). The Institute of Medicine's 2001 report on gaps in health care quality led
to an increased focus on measuring quality and developing financial incentives, Dr.
Chalk said. The Institute is now drafting a report specifically on substance abuse
and mental health.
Constance Horgan, Sc.D., Director of the Schneider Center for Behavioral Health at
Brandeis University, called for a clear and direct link between quality and financing
of services for individuals with co-occurring conditions.
As an example, Dr. Horgan described the work of the Washington Circle, a group of
researchers, substance abuse treatment providers, health care policy experts, and others
convened by CSAT in 1998. The group developed a framework for performance measures
across the continuum of care based in four core domains—prevention/education,
recognition, treatment, and maintenance of treatment effects. To drive quality improvement
in substance abuse treatment, the group has initially developed and tested measures
that focus on the front end of treatment: identification, initiation, and engagement.
Noting that people with alcohol dependence are more likely to have mood disorders, personality disorders, and other drug problems, NIAAA Director Ting-Kai Li, M.D., explained that problem drinkers may be medicating themselves to relieve stress and other conditions.
The National Committee for Quality Assurance, the U.S. Department of Veterans Affairs,
and many public systems have adopted these measures or are considering doing so.
In one study of individuals who get health insurance through large employers, the
group found that private sector health plans needed to improve significantly on ways
to identify substance abusers, and to initiate and sustain treatment.
« See AlsoPrevious
« See Part 1: Complexities
of Co-Occurring Conditions Conference: Experts Identify Problems, Examine Solutions
See AlsoArticle Continued:
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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