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."

SAMHSA's 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 center.

"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.

"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 medications demand.

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.

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