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 - SAMHSA's Leadership in Evidence-Based Practices


SAMHSA's Leadership in Evidence-Based Practices

SAMHSA has played the key Federal role in moving evidence-based practices for co-occurring disorders to the field. With the near doubling of the Federal investment in research, it becomes even more important to shorten the time it takes to bring new clinical findings - including new evidence-based clinical practices - to scale in the community.

SAMHSA has expanded the knowledge base in the treatment of co-occurring disorders, particularly for special populations. Many of the resulting programs have been described in this report. This work includes partnerships with the Agency's colleagues at the National Institutes of Health and the Agency for Healthcare Research and Quality in developing a comprehensive science-to-services agenda responsive to the needs of the field.

The National Evidence-Based Practices Project

The Implementing Evidence-Based Practices for Severe Mental Illness Project is a collaborative project to develop implementation toolkits to promote the delivery of effective practices, including integrated treatment for co-occurring substance abuse disorders and mental disorders. The project is a joint effort being undertaken by SAMHSA, the Robert Wood Johnson Foundation, the National Alliance for the Mentally Ill (NAMI), and State and local mental health organizations in New Hampshire, Maryland, Ohio, Vermont, Oregon, New York, Indiana, and Kansas. It serves as a catalyst to promote development of evidence-based practices at the State and local level. Each of the eight States participating in this project has developed its own center for implementing evidence-based practices, and all eight are also funded by the respective State mental health authorities (Torrey et al., 2001).

Further, SAMHSA has entered into a partnership with the NASMHPD Research Institute, Inc., to establish the NRI Center for Evidence-Based Practices, Performance Measurement, and Quality Improvement. The Center will support a seven-State demonstration project on the feasibility of implementing evidence-based practices using the six toolkits being developed by the Evidence-Based Practices Project.

NASMHPD/NASADAD Joint Task Force on Co-Occurring Disorders

SAMHSA has brokered a critical dialogue between the National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors on the subject of co-occurring substance abuse disorders and mental disorders. As described earlier in this report, outcomes to date have created a strong conceptual foundation on which future efforts can be built.

SAMHSA will continue to support the work of the NASMHPD/NASADAD Task Force as it researches how States respond to the treatment needs of individuals with co-occurring disorders across each of the four quadrants of the agreed-upon conceptual framework for discussing the topic. This work will enhance how States define, develop, and deliver services to these groups, both of which are underrepresented in the current treatment literature.

The National GAINS Center for People with Co-Occurring Disorders
in the Justice System

SAMHSA's National GAINS Center was created in 1995 to collect and disseminate information about effective mental health and substance abuse services for people with co-occurring disorders who come in contact with the justice system. The Office of Juvenile Justice and Delinquency Prevention, the Office of Justice Programs, and the National Institute of Corrections, all of the U.S. Department of Justice, are partners in this effort to Gather information, Assess what works, Interpret the facts, Network with key stakeholders, and Stimulate change. Recently, the Center expanded its efforts to include a focus on youth with co-occurring disorders in the juvenile justice system.

The Women, Co-Occurring Disorders, and Violence Study

In 1998, SAMHSA began the Women, Co-Occurring Disorders, and Violence Study, a 5-year initiative designed to develop, implement, and evaluate integrated systems of care for women with co-occurring substance abuse disorders and mental disorders who have experienced violence and their children. Nine sites are evaluating the effectiveness of comprehensive, integrated service models for women who have co-occurring disorders and histories of physical and/or sexual abuse, and four sites are tailoring and evaluating trauma-informed services for their children. The study is expected to yield significant information about the evidence base for specific interventions and the ways in which services can be integrated across systems. A special Children's Subset Study seeks to reduce risk factors and increase resiliency among children ages 5 to 10 whose mothers have co-occurring disorders and histories of violence.

The Primary Care Research Study in Substance Abuse and Mental Health Services for the Elderly (PRISMe)

The Primary Care Research Study in Substance Abuse and Mental Health Services for the Elderly (PRISMe) - a program collaboration among SAMHSA, HRSA and the Department of Veterans Affairs - is developing and measuring the effectiveness of models to improve the delivery of mental health and substance abuse services to older adults through primary health care. Investigators are collecting data on the most prevalent mental and substance abuse problems (and their co-occurrence) experienced by older adults, measured at baseline, 3-month, and 6-month follow-ups. The study seeks to identify the best tools for screening and assessing older adults with substance abuse and/or mental disorders within primary care settings.

The Targeted Capacity Expansion Program

SAMHSA's Targeted Capacity Expansion (TCE) program for substance abuse treatment helps communities address gaps in treatment capacity by supporting supports rapid and strategic responses to demands for substance abuse treatment, including alcohol and drug use services. Grantees may include communities with serious, emerging drug problems, as well as communities with innovative solutions to unmet needs.

The program, first established in 1998, today funds 33 grants that are focusing on co-occurring substance abuse disorders and mental disorders, providing a wide array of much-needed services. In addition, grantees also are examining questions such as: (1) How do substance abuse and co-occurring mental disorders/other functional disorders affect treatment outcomes? (2) How do client involvement and satisfaction affect treatment outcomes? and (3) What is the relationship between program treatment variables and client outcomes, such as drug use, criminal behavior, service utilization, etc.?

The Co-Occurring Disorders Study

SAMHSA's Co-Occurring Disorders Study is designed to identify existing models of substance abuse treatment for people with co-occurring disorders and evaluate their effectiveness based on client outcomes and costs. Grantees are examining and evaluating such approaches as a model of brief trauma treatment for outpatient substance abuse care; a comparison of outcomes from parallel and integrated treatment approaches for individuals with a mental illness addicted to heroin; specific treatment approaches for persons with substance abuse and post traumatic stress disorder or depression, and the effectiveness of integrated treatment for individuals with co-occurring disorders of mild to moderate severity. Results of these studies, which include rigorous evaluation designs, will further inform the field about evidence-based practices for co-occurring disorders. Results will be available in 2003-2004.

Community Action Grants for Service System Change

SAMHSA's Community Action Grant for Service System Change program operates in both the mental health services and substance abuse treatment domains. The mental health-related grant program supports the adoption and implementation of exemplary services practices for children with serious emotional disturbance or adults with serious mental illness, including those with co-occurring substance abuse disorders. Phase I grants support consensus-building among key stakeholders to adopt an exemplary practice in their community or State; phase II grants support implementation of the practice with funds for training and other non-direct services.

Fourteen grantees have focused specifically on integrated treatment for people who have co-occurring disorders. Seven of the grant programs represent State-level initiatives in Arizona, Louisiana, Maine, Massachusetts, New Hampshire, New York, and Vermont. Another seven are being conducted in local communities.

In addition, several of the grants for co-occurring disorders are designed to serve the particular needs of minority and other underserved groups, among them Latino clients with co-occurring disorders in the justice system; American Indian adults and adolescents at risk for co-occurring disorders and those already in substance abuse treatment; and integrated co-occurring disorders treatment for Asian clients in primary care settings. Results will yield important evidence about consensus building and the adoption of exemplary practices for co-occurring disorders.

Likewise, the substance abuse treatment-related Community Action Grant program provides support for service system change and for the adoption and implementation of exemplary practices for substance abuse treatment, including treatment for co-occurring disorders. Grantees funded to implement changes in services for people with co-occurring disorders have focused on different age populations across the lifespan.

Recovery Community Services Program

SAMHSA's Recovery Community Services Program provides support to allow people in recovery from substance abuse and their family members to design and deliver peer services that help prevent relapse and promote long-term recovery. This initiative is directed toward individuals with both substance use disorders and co-occurring substance abuse disorders and mental disorders.

One such project is training individuals with co-occurring disorders to develop and conduct self-help support groups designed specifically to meet the special needs of people in recovery who also have a psychiatric disorder. It uses the "Dual Diagnosis Anonymous" model. Another project serves individuals with co-occurring substance abuse and mental illness disorders and their families. It offers peer support, life skills education, alcohol- and drug-free social activities, and leadership development training.

Projects for Assistance in Transition from Homelessness (PATH)

SAMHSA administers the Projects for Assistance in Transition from Homelessness formula grant program, established by Congress in 1991 to help States and Territories provide flexible, community-based services for people who are homeless and have serious mental illnesses, including those who have co-occurring substance abuse disorders. PATH-funded providers must be able to address the needs of people who have co-occurring disorders in a coordinated manner.

In addition to outreach, which is the most frequently funded PATH service, providers offer screening and diagnosis, rehabilitation, mental health and substance abuse treatment, case management, limited housing assistance, and referrals to other services, job training, and education. A PATH-funded technical assistance provider helps States and Territories implement evidence-based practices (Winarski, 1998).

The President pledged additional support in fiscal year 2003 to SAMHSA programs that serve people who are homeless and who have addictive and/or mental disorders, including a proposed $7 million increase for PATH. Other SAMHSA programs that focus on the special needs of people with serious mental illnesses and/or co-occurring substance abuse disorders who are homeless include the Homeless Families Initiative, described below, and the ACCESS program, highlighted previously in this chapter.

The Homeless Families Initiative

The Homeless Families Initiative is documenting and evaluating the effectiveness of short-term interventions to encourage movement out of homelessness, stability in housing, decreased alcohol and drug use, family preservation, and improvements in mental health and social functioning for women with mental health and/or substance abuse disorders who are homeless and caring for their dependent children. The program interventions include mental health and substance abuse treatment, trauma recovery, housing, support, and family preservation services. Program results will be used to disseminate information on effective interventions to States, counties, and communities to help them address issues affecting homeless families, including the problem of co-occurring disorders.

Addiction Technology Transfer Centers (ATTCs) and Centers for Application of Prevention Technology (CAPTs)

SAMHSA uses regionally based Centers to assist communities in adopting evidence based practices in the prevention and treatment fields. ATTCs are a nationwide, multidisciplinary resource that helps treatment systems adopt or adapt evidence-based practices for people with substance abuse disorders, including those with co-occurring mental disorders by transmitting the latest knowledge and skills in professional addiction treatment practice. CAPTs perform the same functions and are structured similarly to ATTCs except that they provide knowledge around evidence-based prevention strategies.

ATTC resources on co-occurring disorders include an online course, Assessment of Substance Abuse Related and Mental Disorders, as well as a variety of curricula on a broad range of topics relating to the treatment of people with co-occurring disorders. Some of these are highlighted in the technical assistance document, Strategies for Developing Treatment Programs for People with Co-Occurring Substance Abuse and Mental Disorders.

SAMHSA Education and Training Tools

SAMHSA has developed a series of Treatment Improvement Protocols (TIPs) designed to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug abuse. Each of the 38 separate TIPs to date reflects a careful consideration of all relevant clinical and health services findings, demonstration experience, and implementation requirements. One of the TIPs, Substance Abuse Treatment for Persons with Co-Occurring Disorders, currently in press, features detailed information on the evidence-based practices highlighted in this chapter. Each TIP features specific guidance to help practitioners implement evidence-based practices with clients in the field.

The Center for Mental Health Services, in conjunction with Dartmouth University and the Robert Wood Johnson Foundation, has developed the toolkit on co-occurring substance abuse disorders and mental disorders, within the Implementing Evidence-Based Practices for Severe Mental Illness Project, a clinician, consumer, and family oriented education and training module for the implementation of evidence-based practices in providing integrated mental health and substance abuse treatment for individuals with co-occurring disorders in the community-based mental health care system (SAMHSA, in press).

SAMHSA's technical assistance report, Strategies for Developing Treatment Programs for People with Co-Occurring Substance Abuse and Mental Disorders (The National Council and SAAS, 2002), includes lessons learned from program and systems-level experts in the development of program-level strategies and systems-level approaches for co-occurring disorders.

TIPs, toolkits, and SAMHSA reports are available through SAMHSA's National Mental Health Information Center. These resources are available online at