Triple Diagnosis: Surmounting the Treatment Challenge (Part 1)
By Rebecca A. Clay
Jane* and her health care providers knew she had three
big problems. She'd been diagnosed with HIV. She was suffering
from depression. She was addicted to heroin. Unfortunately, only
one of her providers knew she had a fourth problem.
When Jane's health care providers finally started talking,
the physician from the HIV/AIDS clinic Jane sporadically attended
revealed that Jane also had hepatitis. That wasn't the only
surprise for the other clinicians treating her. It turned out the
depression medication and the methadone they were giving her made
her hepatitis worse. By the time the physician called Jane in to
check her liver functioning, it was too late. Soon after, she died
of liver failure.
"Jane is a poster child for the need to integrate care,"
said Marcia D. Andersen, Ph.D., R.N., F.A.A.N., C.S., who arranged
the meeting of Jane's caregivers in her role as vice president
of the Well-Being Institute, Inc., in Detroit, MI. "When you
get providers talking to each other, you can save lives."
Center for Mental Health Services (CMHS), together with several
other Federal entities, is seeking solutions to scenarios like Jane's.
Launched in 1998, the 5-year HIV/AIDS Treatment Adherence, Health
Outcomes, and Cost Study will determine whether integrating treatment
for HIV/AIDS, mental illness, and substance abuse for "multiply
diagnosed" people like Jane can improve adherence to treatment regimens,
enhance health, and provide cost-effective services.
The Well-Being Institute and seven other sites across the Nation
(see Participating Sites) are testing
various models of integration with the assistance of a coordinating
"With new medications, people with HIV/AIDS are living much
longer," said Federal program director Mary C. Knipmeyer,
Ph.D., of the CMHS Office of the Associate Director for Medical
Affairs. "We need to know how to help people face the challenges
of adhering to complicated new HIV/AIDS treatment regimens while
taking other medications for their mental and addictive disorders.
We also need to know how to provide cost-effective care."
In keeping with the study's emphasis on integrating various
treatment realms, the project is a collaboration among six Federal
entities. While CMHS has the lead administrative responsibility,
SAMHSA's Center for Substance Abuse Treatment (CSAT), the
HIV/AIDS Bureau at the Health Resources and Services Administration,
and the National Institute of Mental Health, National Institute
on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism
at the National Institutes of Health are all actively involved.
Representatives from each organization participate in a Federal
collaborators group as well as the study's steering committee.
A representative from each site, a representative from the coordinating
center, and a consumer liaison comprise the steering committee.
| Members of the Well-Being
Institute's outreach team gather in front of the program's outreach
"Having so many Federal entities involved is unusual,"
said Jennifer Todd, Dr.P.H., a social science analyst in CSAT's
Division of Practice and Systems Development. This kind of interagency
collaboration does more than just provide a model of the kind of
integration the Federal Government would like to see at the local
level. It also helps each organization fulfill its mission. "Ultimately
we're all serving the same people, so it's important
that we coordinate as a team," explained Dr. Todd. "Although
it can be harder to get consensus in a large group, in the long
run it will help us better serve people with multiple disorders."
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A Treatment Challenge
Although treatment advances have improved the prospects of people
living with HIV/AIDS, mounting research suggests that those who
also have mental and addictive disorders are least able to take
advantage of these life-prolonging medications. What's more,
treating these multiply diagnosed individuals costs more than treating
other people with HIV/AIDS.
"Individuals with these diagnoses often are unable to participate
in antiviral regimens because their mental health and substance
use disorders get in their way," explained principal coordinating
center director James Bell, M.A., president of James Bell Associates
in Arlington, VA. The combined effects of addiction and mental disorders
along with the struggle to meet basic survival needs like food and
shelter can keep people from making health a priority. Even when
they receive antiviral prescriptions, their other disorders can
make it hard for them to stick to the complicated regimens these
Dr. Knipmeyer noted that the stigma of mental illness and substance
abuse discourages some physicians from even offering or suggesting
complicated medication regimens.
Although study sites offer different interventions, all use the
same assessment tools to track participants' progress from
the time they begin to 1 year later.
This standard battery includes such elements as:
- Structured Clinical Interview for the Diagnostic and Statistical
Manual IV designed to determine accurate mental health
and substance use diagnoses
- Addiction Severity Index-Lite to track substance
abuse, a modified form of the Adults AIDS Clinical Trials Group
Adherence Instrument designed to track changes in treatment adherence
- Health Services Utilization Questionnaire that
assesses utilization costs.
The individual projects also are drawing on data from medical
charts, administrative records, and random urine sampling.
By the time the study ends, the eight study sites will have extensive
data from more than 1,000 individuals.
*Name changed to protect privacy.
See AlsoArticle Continued: Part 2 »
AlsoRelated ContentParticipating Sites »
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