SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 4 - Evidence-Based practices for Co-Occurring Disorders - Program Structures and Settings


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Program Structures and Settings

Evidence-based practices for individuals with co-occurring disorders are provided in the context of service programs in substance abuse, mental health, primary health, and other behavioral health and human services systems, and in inpatient, outpatient, community-based or residential settings.

Because no single intervention can meet the needs of all people experiencing co-occurring substance abuse disorders and mental disorders, programs working in this area are necessarily complex in structure. They must be able to organize multiple services across what may be multiple service systems. They also must be able to guide the implementation of evidenced-based practices that are tailored to the unique needs of the clients - practices that include interventions developed in the substance abuse, mental health, and other related fields specifically to address co-occurring disorders among individuals and their families (Minkoff, 2001; CMHS, 1998).

The most effective programs support the delivery of a comprehensive array of evidenced-based practices that not only reflect the diversity of individuals with co-occurring substance abuse disorders and mental disorders, but also the spectrum of service need based on impairment and disability (Minkoff, 1991). Two diagnostic tools exist to help ensure that programs provide the level of care that is most appropriate for each individual: The Diagnostic and Statistical Manual, Fourth Edition (DSM-IV), and the Patient Placement Criteria for the Treatment of Substance-Related Disorders.

DSM-IV classifies both mental and substance-related disorders, providing clinicians with a common language to communicate about these disorders and to make clinical decisions. Specific minimum symptoms, including type and duration, are presented for each scientifically validated diagnosis included in the volume to help guide clinical diagnosis. The criteria also help clinicians distinguish among substance-induced mental disorders, substance problems attributable to psychiatric syndromes, and disorders meeting the criteria for co-occurring disorders.

The American Society for Addiction Medicine (ASAM) Patient Placement Criteria (2R) (ASAM, 1995, 2001) - guidelines to assess and determine care needs for people with substance abuse and other co-occurring disorders - delineate three types of programs to serve people with co-occurring substance abuse disorders and mental disorders: (1) addiction only; (2) dual-diagnosis capable in which less severe mental problems (some of which may not even reach diagnostic criteria) are able to be treated; and (3) co-occurring enhanced that provides a high degree of integrated substance abuse treatment and mental health services for people with considerably severe symptoms and impairment.

The National Registry of Effective Prevention Programs

To help program planners, and policy makers learn more about and be able to identify and implement the best evidence-based prevention programs in their States and communities, SAMHSA has established the National Registry of Effective Prevention Programs (NREPP) with the specific mandate to identify, review, and disseminate evidence-based effective prevention programs (CSAP, 2001). Starting in 2002, NREPP will be used as the Federal "seal of approval" for prevention programs targeting co-occurring substance abuse disorders and mental disorders.

The NREPP also helps address common methodological flaws in prevention program evaluations, including small samples, self-selection of participants, participant attrition and insufficient long-term follow-up, as reported in the Cochrane Review of Randomized Trials for Substance Abuse and Schizophrenia (in Dorfman, 2000; Ley et al., 2000; Heller, 1996). It also helps address issues identified by Greenberg (1999) such as lack of replication, little attention to how the quality of the implementation affects outcomes, and the need to measure multiple dimensions.

Programs nominated for candidacy each year are reviewed against a stringent set of criteria and are ranked based on scientific rigor of their evaluation and the practicality of their findings for substance abuse prevention. Based on those standards, programs that cross the first bar are then judged to be effective, model, or promising - the equivalent of gold, silver and bronze awards for excellence.

To move information about these high quality programs to the field where they can be adopted and adapted to local needs, SAMHSA established the internet-based National Dissemination System. SAMHSA also works in collaboration with such national organizations as the National Mental Health Association, the National Head Start Association, and the National Association of Elementary School Principals to disseminate information about effective programs.

Organizing Services: The Four Quadrant Framework

As discussed in Chapter 1, the four quadrant framework (see Figure 1.1), adopted and refined by the NASMHPD/NASADAD Joint Task Force on Co-Occurring Disorders, can help substance abuse and mental health providers and systems better conceptualize and organize the range of services that can best meet the needs of individuals with multiple symptoms and varying degrees of severity. It also can help frame service coordination needs along the full continuum of care as well as the locus for that care.

The NASMHPD/NASADAD Task Force recommended that when it comes to providing care for people with co-occurring disorders, mental health, substance abuse and primary care service providers must adopt different ways of working with each that are consistent with the framework described above (NASMHPD/NASADAD, 1999).

Consultation. Quadrant I (both disorders less severe): Informal relationships among providers that ensure both mental disorders and substance abuse problems are addressed, especially with regard to identification, engagement, prevention, and early intervention. An example of such consultation might include a telephone request for information or advice regarding the etiology and clinical course of depression in a person abusing alcohol or drugs.

Collaboration. Quadrant II/III (one disorder more severe, the other less severe): More formal relationships among providers that ensure both mental disorders and substance abuse problems are included in the treatment regimen. An example of such collaboration might include interagency staffing conferences where representatives of both substance abuse and mental health agencies specifically contribute to the design of a treatment program for individuals with co-occurring disorders and participate in service delivery.

Integrated Services. Quadrant IV (both disorders more severe): Relationships among mental health and substance abuse providers, in which the contributions of professionals in both fields are merged into a single treatment setting and treatment regimen. Integrated treatment is "any mechanism by which treatment interventions for co-occurring disorders are combined within the context of a primary treatment relationship or service setting" (CSAT, in press). Such treatment exists on a continuum that ranges from cross-referral and linkage, through cooperation, consultation, and collaboration, to integration in a single setting or treatment model (CSAT, in press).

This four-quadrant framework is especially useful because it encompasses the full range of people with co-occurring substance abuse disorders and mental disorders. It supports the "windows of opportunity" for preventing more serious disorders or exacerbation of symptoms in all age groups (NASMHPD/NASADAD, 1999). For example, prevention and early intervention are appropriate for individuals in quadrant I, for whom any mental and substance abuse problems they might have would not require specialty care. Strategies can also be applied to quadrants II, III and IV to prevent increases in mental or substance abuse disease severity. People with the most severe disorders are the most difficult and expensive to treat and require the highest level of coordinated services. The quadrants also provide a valuable framework for coordinating care with family members, and for planning and coordinating programs and services, as well as managing available resources.


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