Report to Congress - Nov 2002
REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE DISORDERS AND MENTAL DISORDERS
Seven to 10 million individuals in the United States "have at least one mental disorder1 as well as an alcohol or drug use disorder" (U.S. DHHS, 1999; SAMHSA National Advisory Council, 1998). Further, as indicated by the U.S. Surgeon General in the 1999 report on mental health: "Forty-one to 65 percent of individuals with a lifetime substance abuse disorder also have a lifetime history of at least one mental disorder, and about 51 percent of those with one or more lifetime mental disorders also have a lifetime history of at least one substance abuse disorder" (U.S. DHHS, 1999). Individuals experiencing these disorders simultaneously - in this report, referred to as co-occurring disorders - have particular difficulty seeking and receiving diagnostic and treatment services, even though, separately, these disorders often are as treatable as other chronic illnesses. Clearly, co-occurring substance abuse disorders and mental disorders present significant challenges to the Nation's public health and to health policy makers as well.
In part, the stigma that still is associated with substance abuse disorders and mental disorders stands between many people with co-occurring disorders and successful treatment and recovery. Further, the difficulty is compounded by the existence of two separate service systems, one for mental health services and another for substance abuse treatment. Too often, when individuals with co-occurring disorders do enter specialty care, they are likely to bounce back and forth between the mental health and substance abuse service systems, receiving treatment for the co-occurring disorders serially at best. It is not surprising that high rates of co-occurring substance abuse disorders and mental disorders are seen in primary care settings. With training and other supports, these settings will be well prepared to undertake diagnosis and treatment of these complex, chronic and interrelated disorders.
If one of the co-occurring disorders goes untreated, both usually get worse and additional complications often arise. The combination of disorders can result in poor response to traditional treatments and increases the risk for other serious medical problems (e.g., HIV, Hepatitis B and C, cardiac and pulmonary diseases), suicide, criminalization, unemployment, homelessness, and separation from families and communities. As a result, individuals with co-occurring disorders often require high-cost services such as inpatient and emergency room care.
The clinical reality of co-occurring disorders challenges the Nation's traditional mental health and substance abuse service and treatment systems. However, an increasing number of evidence-based interventions and programs demonstrate that treatment can be improved with integrated services and treatments. As defined in this report, integrated treatment refers broadly to "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). This report acknowledges that effective treatment includes time sensitive screening, comprehensive assessment and program-oriented and specific clinical interventions of medications and psychosocial treatments.
This report has been prepared by the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (HHS), under the mandate of Section 3406 of the Children's Health Act of 2000 (Public Law 106-310), Section 503A of the Public Health Service Act. SAMHSA - with its Center for Mental Health Services (CMHS), Center for Substance Abuse Treatment (CSAT), and Center for Substance Abuse Prevention (CSAP) - is in a unique position not only to identify and describe the current status of services for people with co-occurring substance abuse disorders and mental disorders, but also to facilitate the coordination and appropriate integration of treatment services to meet the special needs of these millions of Americans. This report includes both underlying guiding principles and a plan for SAMHSA to guide action at the National, State and local levels to redress current weaknesses and enhance strengths in accountability, capacity, and effectiveness of treatment and prevention services for people with co-occurring substance abuse disorders and mental disorders. These principles are consistent with the President's New Freedom Initiative, which will help those with co-occurring disorders gain the supports they need to reside in, and have a meaningful life as part of, their communities.
The content of this report includes a response to each of four statutory requirements:
· A summary of the manner in which individuals with co-occurring disorders are receiving treatment;
· A summary of practices for preventing substance abuse disorders among individuals who have a mental illness and are at risk of having or acquiring a substance abuse disorder;
· A summary of evidence-based practices for treating individuals with co-occurring mental illness and substance abuse disorders and recommendations for implementing such practices; and
· A summary of improvements necessary to ensure that individuals with co-occurring disorders receive the services they need.
Members of SAMHSA's National Advisory Council Subcommittee on Co-Occurring Disorders, as well as a distinguished panel of experts and representatives from a broad range of substance abuse and mental health constituencies, joined with SAMHSA staff to consult and to develop this report to Congress. The report responds not only to the congressional mandate, but also to the imperative for action demanded by SAMHSA's citizen-centered, results-driven approach to services.
The extensive input provided by SAMHSA constituencies (including consumers and recovering persons; family members; advocates; service providers; researchers; national provider, consumer and family organizations; State, tribal, and local government representatives; and other research and services experts in the field) highlighted current impediments to serving individuals with co-occurring disorders and identified a host of recommendations for change (SAMHSA, 2002b). At the same time, SAMHSA sought out investigators working at the cutting edge of services research into best ways of reaching, assessing and providing treatment and other services for persons with co-occurring disorders. As a result, the report reflects the current state-of-the-science in evidence-based approaches that appear to be most successful. It also identifies areas in which additional investigation is warranted.
One of the most productive and beneficial results of the process leading to submission of the report has been the broadened and deepened dialogue about co-occurring disorders which will help direct SAMHSA's ongoing work in this area. The theme of the dialogue was both consistent and persistent: Improving the Nation's public health demands prompt attention to the problem of co-occurring disorders.
People with co-occurring disorders have lives and families, hopes and dreams, responsibilities and needs. They can be mothers, fathers, grandparents, students, teachers, plumbers, or pianists. They may also have HIV/AIDS, be victims of physical or sexual abuse, be homeless, or be involved with the criminal justice system. Too often, these individuals pay a high price for having co-occurring disorders: lost dreams, lost families, and, in some cases, lost lives. Knowledge of interventions and programs that work is increasing; the best are both person-centered and results-driven. That new knowledge must be shared and used.
Co-occurring disorders are common; they affect from 7 to 10 million adults in the U.S. each year (U.S. DHHS, 1999; SAMHSA National Advisory Council, 1998). Children, youth, and older adults also may experience co-occurring substance abuse disorders and mental disorders. For youths, one study revealed that nearly 43 percent of youth receiving mental health services in the United States have been diagnosed with a co-occurring disorder (CMHS, 2001). Further, the SAMHSA annual National Household Survey on Drug Abuse (NHSDA) for the first time, in 2001, included questions for youths and adults that measure serious mental illness (SMI)1. The Survey found a strong relationship between substance abuse and mental problems, as described below (SAMHSA, 2002e).
According to the 2001 NHSDA, there were an estimated 14.8 million adults age 18 or older with serious mental illness. This represents 7.3 percent of all adults. Of those with SMI, 6.9 million received mental health treatment in the 12 months prior to the interview. Among adults with SMI, 20.3 percent were dependent on or abused alcohol or illicit drugs; the rate among adults without SMI was 6.3 percent. An estimated 3 million adults had both SMI and substance abuse disorders or dependence problems during the year.
Although limited information is available on the prevalence of co-occurring disorders in older adults, it is known that, like children and youth, older adults with mental disorders may be especially prone to the adverse effects of drugs or alcohol. The presence of severe mental illness may create additional biological vulnerabilities such that even small amounts of psychoactive substances may have adverse consequences for individuals with schizophrenia or other brain disorders (Drake et al., 1998).
Both substance abuse disorders and mental disorders have biological, psychological, and social components. Part of the complexity of treating these disorders when they co-occur is that both primarily affect the same part of the body - the brain - a factor that complicates treatment, including the use of medications.
Screening and assessment, the very first steps in the process of identifying and treating individuals with co-occurring substance abuse disorders and mental disorders, are similarly complicated. Oftentimes these individuals minimize or deny the existence of their disorders in the first place; they do not enter the door to services willingly or often. When they do enter the service system, mental disorders may be masked by substance abuse; obversely, what appear to be mental disorders may be the product of substance abuse complicating evaluation and assessment.
Difficulty arises even when evaluation and assessment identify co-occurring disorders. Individuals with co-occurring disorders may be excluded from mental health programs due to their substance abuse disorder, and from substance abuse treatment programs because of their mental disorder.
What makes the issue important is the fact that individuals with co-occurring disorders should be the expectation, not the exception in the substance abuse and mental health treatment systems. From studies and first-hand experience, many researchers and clinicians believe that both disorders must be addressed as primary and treated as such (Drake et al., 1991). A further reality is that an individual with a mental disorder is at increased risk for developing a substance abuse disorder and, conversely, that a person with a substance abuse disorder is at increased risk for developing a mental disorder.
As with both substance abuse disorders and mental disorders separately, no one kind of co-occurring disorder defines all people who experience it. Co-occurring disorders vary by severity, chronicity, symptomatology, degree of impairment, and motivation to address the problem.
The public mental health service system tends to address individuals with severe and chronic mental illnesses such as schizophrenia, bipolar disorder, borderline personality disorder, and major depression. Typically, it is not equipped to address the treatment of concurrent substance abuse disorders. The substance abuse treatment system addresses all types of substance abuse disorders at all levels of severity; when necessary, many providers in this system are able to respond to mild to moderate forms of mood, anxiety, and personality disorders. The public substance abuse and mental health service systems differ markedly with respect to staffing resources, philosophy of treatment, funding sources, community political factors, regulations, prior training of staff, credentials of staff, treatment approaches, medical staff resources, assertive community outreach capabilities, and routine types of evaluations and testing procedures performed.
Numerous barriers have limited the capacity of both the substance abuse and mental health treatment systems to meet the needs of persons with co-occurring disorders. Federal, State, and local infrastructures generally are organized to respond to single, not co-occurring, disorders. Mental health and substance abuse service systems often vie for the same limited resources. Funding mechanisms do not encourage flexible, creative financing across the substance abuse and mental health systems to foster better service capacity for people with co-occurring substance abuse disorders and mental disorders.
In addition, staff licensure requirements vary according to treatment setting; treatment models themselves vary by setting. Clinicians in the two different systems frequently have different credentials, training, and treatment philosophies. Salaries, too, vary widely - an important factor affecting workforce recruitment and retention.
Thus, to receive needed treatment, individuals with co-occurring substance abuse disorders and mental disorders must negotiate what today are separate systems that are not always best able to meet the full range of their needs. Insufficient coordination has been criticized on both clinical and practical grounds. Youth with co-occurring substance abuse disorders and mental disorders and their families infrequently get the kind of help they need at the time they need it. Services and supports are fragmented, isolated, and often rigid (Federation of Families, 2000). As one observer noted, "Our consumers do not have the opportunity to separate their addiction from their mental illness, so why should we do so administratively and programmatically?" (Osher, 2001).
Data show a significant gap between the need for treatment and the receipt of care. One study found that while 7 to 9 percent of all Medicare/Medicaid enrollees surveyed had evidence of either a substance abuse disorder or a mental disorder or both, treatment rates were only from 0.2 to 0.9 percent for people experiencing co-occurring disorders. Further, preliminary results from a follow-up study to the 1996 National Co-morbidity Survey Replication find that of those with co-occurring disorders, only 19 percent of those studied receive treatment for both disorders; 29 percent do not receive treatment for either disorder (see Chapter 1).
Substance abuse and mental health treatment providers well recognize that individuals with co-occurring disorders present complicated, chronic, interrelated conditions that often require solutions that are personalized to the specific set of symptoms, level of severity, and other psychosocial and environmental factors. Thus, treatment plans must be individualized to address each person's specific needs using staged interventions and motivational enhancement to support recovery. To ensure individuals with co-occurring disorders receive needed services, many State and local substance abuse and mental health authorities are planning, implementing, and/or enhancing systems change approaches to address co-occurring disorders, including such options as aggregating Federal, State and local funds.
Not surprisingly then, the provision of integrated treatment ranges across a continuum spanning single cross-referral and linkage; through cooperation, consultation, and collaboration; to integration in a single setting or treatment model (CSAT, in press). Such treatment is provided through three levels of service provision:
1. Integrated Treatment - interaction between the mental health and/or substance abuse clinician(s) and the individual, which addresses the substance abuse and mental health needs of the individual.
2. Integrated Program(s) - the organizational structure for providing integrated treatment, the mental health and/or substance abuse program is responsible for ensuring an array of staff or linkages with other programs to address all of the needs of its clients. The program is responsible for ensuring that services are provided in an appropriate and easily accessible setting, services are culturally competent, etc.
3. Integrated System - the organizational structure for supporting an array of programs for people with different needs, including individuals with co-occurring substance abuse disorders and mental disorders. The system is responsible for ensuring appropriate funding mechanisms to support the continuum of services needs, addressing credentialing/licensing issues, establishing data collection/reporting systems, needs assessment, planning and other related functions.
Because significant differences between the substance abuse and mental health systems persist, a common framework has been needed to help clarify how co-occurring disorders can best be understood and discussed from both policy and program perspectives. To provide such a common language, the co-occurring disorders conceptual framework (depicted below) was developed by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD).
The framework provides a mechanism in addressing symptom severity and level of service system coordination on a continuum from less severe to more severe disorders, and from consultation and collaboration to integration, respectively. While displayed as a simple four-quadrant matrix, it encompasses the full range of co-occurring substance abuse disorders and mental disorders (NASMHPD/NASADAD, 1999).
The framework is not intended as a way to classify individual clients; rather, it displays the universe of individuals with co-occurring disorders (CSAT, in press). In addition, the conceptual framework specifies the level of service coordination needed by those persons in each of the quadrants. The greater the severity, the more intense the level of coordination required. Finally, the conceptual framework points to various windows of opportunity within which providers can act to prevent or deter the development of more serious disorders or the exacerbation of symptom severity for individuals of all ages.
Care for people with co-occurring substance abuse disorders and mental disorders takes place at the State and local level. The two SAMHSA-administered block grant programs - the Substance Abuse Prevention and Treatment (SAPT) Block Grant and the Community Mental Health Services (CMHS) Block Grant - are sources of funds that can serve as a catalyst for the development of innovative State and local programs for people with co-occurring disorders. The two block grant programs may do so as long as all funds are used in accordance with the specific regulatory and statutory requirements that govern them under Section 1956 of the U.S. Public Health Service Act, which includes reporting and auditing requirements.
A key feature of both the SAPT and CMHS Block Grants is the flexibility each State has to target funds for co-occurring disorders based on community need. Many States have used funds from both Block Grants, in compliance with the regulatory and statutory requirements, to provide services to individuals with co-occurring substance abuse disorders and mental disorders.
Under the provisions of P.L. 106-310, SAMHSA's reauthorizing statute, SAMHSA was directed to realign the regulations governing the Block Grant programs consistent with the concept of Performance Partnerships. Such partnerships provide States even greater flexibility in the use of Block Grant funds. Performance Partnerships also mandate State accountability through performance measures with clearly defined outcomes, encouraging not only continuous quality improvement, but also a high level of responsiveness to consumers of substance abuse and mental health services.
Many States use their Block Grant funds, aggregated with other funding sources (e.g., State and Medicaid funds), to support multiple activities related to co-occurring disorders. These include strategic planning, training, residential and outpatient services, services for children and adolescents, and consumer support interventions, among others (NASMHPD/NASADAD, 2002).
While both Block Grant programs span the States, Territories, and the District of Columbia, and while both support technical assistance, data collection and evaluation, they are distinguished from each other in a number of notable ways. The fiscal year 2002 SAPT Block Grant appropriation was $1.725 billion, accounting for 40 percent of State expenditures for substance abuse prevention and treatment services (NASADAD, 2002). The CMHS Block Grant funds in the same fiscal year totaled $433 million, accounting only for between 3 and 4 percent of State expenditures for community-based mental health care. Regarding the larger picture of national spending on mental and substance abuse disorders, the total expenditure for mental health and substance abuse for 1997 (latest available data) was $82.2 billion. Of this amount, spending for mental health was $70.8 billion (representing 86 percent) and spending for substance abuse accounted for $11.4 billion (or 14 percent) (SAMHSA, 2000a).
SAPT Block Grant funds can be used for the provision of direct substance abuse treatment services without regard to the severity of an individual's substance abuse disorder, while the CMHS Block Grant funds may only be used to meet the needs of adults with serious mental illnesses and children with serious emotional disturbances.
The SAPT Block Grant does not require that services be provided to or reported for individuals with co-occurring disorders. In contrast, State mental health plans must include information about the ways in which the issue of co-occurring substance abuse disorders and mental disorders will be addressed both for adults with serious mental illnesses and children with serious emotional disturbances. Without such information, States are at risk of not receiving CMHS Block Grant funds.
Though scant research has been conducted on the prevention of co-occurring substance abuse disorders and mental disorders, the limited data available suggest that since some of the risk factors for mental and substance abuse disorders may be identical, (e.g. low socioeconomic status, family conflict, exposure to violence), programs designed to prevent one disorder may prevent or forestall development of the other.
This may be especially true for adolescents, for whom emotional and behavioral problems, social problems, and risky health behaviors often co-occur as an organized pattern of adolescent risk factors (Greenberg et al., 2000). Children and adolescents already experiencing serious mental disorders are at heightened risk for substance abuse disorders. This suggests the existence of a "window of opportunity" in which it may be possible to prevent the development of co-occurring substance abuse disorders in these youth by intervening early (SAMHSA, 2000; Ziedonis, 1995). For these children and adolescents, comprehensive programs that are family-focused, culturally appropriate, and available on a long-term basis have been shown to reduce problems at school and with the juvenile justice system, increase family cohesion and effective parenting, and decrease substance use/abuse.
Adults (including older adults) also may benefit from preventive interventions. Key life changes may precipitate mental and/or substance abuse disorders in vulnerable individuals. Older adults, in particular, are at special risk for prescription drug misuse and alcohol-related problems, as well as for depression and suicide. Prevention programs that include outreach and support can help increase the protective factors that mitigate against these outcomes. Early identification and intervention, reinforced by appropriate alcohol and drug testing, where needed, also may prevent or deter development of more serious problems or exacerbation of symptoms in adults and older adults with co-occurring disorders.
The extent to which individuals with co-occurring substance abuse disorders and mental disorders began to emerge as a public health concern in the early 1980s when it became evident that a significant number of people with serious mental illnesses also had substance abuse disorders. Initial studies and reports in the mid-1980s, many commissioned by the Federal Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), the predecessor of SAMHSA, revealed that most mental health and substance abuse treatment systems were not addressing the problem of co-occurring disorders effectively (Ridgely et al., 1990).
At the same time, the two systems were not addressing the broad needs of people with either mental or substance abuse disorders as well as they might. The mental health system divided treatment into either treatment with medicine or treatment with "talk" therapy. Today, "integrated treatment" for many individuals includes both medications and psychosocial treatments. Similarly, the substance abuse treatment system divided its services into either "alcohol" or "drug" treatment. Today most substance abuse treatment programs address both alcohol and drug problems.
Historically, individuals with co-occurring disorders received sequential or parallel treatment from the separate mental health services and substance abuse treatment systems. Neither system had developed the capacity to provide both mental health and substance abuse treatment within a single program. Fragmented and uncoordinated services created a service gap for persons with co-occurring disorders.
Both substance abuse and mental health programs must be able to assess new clients in a comprehensive manner, and programs must develop different types of specialized integrated services based on the individuals they expect to treat. In some cases, being able to provide an antidepressant treatment for individuals with mild to moderate depressive disorders seen in substance abuse treatment settings will be both "integrated" and improve outcomes. Integrated treatment programs vary in their depth and range of services, and clinicians must also continue to improve their skills to deliver integrated treatment and to know their limitations and when to also refer and coordinate with other providers.
Mental Health Research: Controlled research studies - both experimental and quasi-experimental - of co-occurring disorders programs for people with serious mental illnesses and substance abuse disorders in mental health settings reveal positive outcomes for integrated treatment programs (Drake et al., 1998). These studies have been summarized recently in the literature (Drake et al., 2001) and form the basis for the soon-to-be completed and evaluated toolkit on co-occurring substance abuse disorders and mental disorders within the Implementing Evidence-Based Practices for Severe Mental Illness Project (SAMHSA, in press).
Better identifying and treating both the substance abuse disorder and the mental disorder not only improve outcomes, but also appear to be cost-effective. The limited data on costs and cost-effectiveness of various types of co-occurring disorders treatment are mixed (Greenberg, 2002). However, some studies have begun to show both that specific interventions for co-occurring disorders may be cost effective, and that societal costs to care for these individuals may be reduced, as well (Jerrell et al., 1994).
Substance Abuse Research: In a similar manner, there is a growing literature in the alcohol, nicotine, and drug abuse research fields - using well controlled studies that have evaluated specific interventions for specific subtypes of co-occurring disorders - that demonstrate improvements in outcomes. SAMHSA is funding a number of grant and demonstration programs focusing on innovative approaches, including integrated treatment, for co-occurring substance abuse disorders and mental disorders. In addition to these programs, many research studies have evaluated the addition of specific medications and psychosocial treatment approaches to a wide variety of co-occurring disorder subgroups (e.g., cocaine addiction and depression; tobacco and depression; alcohol, cocaine, and panic disorder; personality disorder; mild depression; and poly-drug dependence). The Behavioral Therapies Development Program and the Medication Development Program of the National Institute on Drug Abuse have begun to help clinical researchers develop and test specific integrated treatments for specific subtypes.
Studies within substance abuse and mental health settings have demonstrated that integrated treatment is successful in retaining individuals who have co-occurring disorders in substance abuse treatment, reducing substance abuse disorders, and reducing symptoms of mental disorders. These studies have included very structured studies of specific subtype combinations (schizophrenia and alcohol dependence) and general clinic program evaluations of all in treatment. As the field progresses there is a great need for more research of specific interventions and program evaluations, including cost-effectiveness. For example, in the mental health setting, research on the use of medications to aid in the treatment of substance abuse disorders is lacking and needed (antabuse, naltrexone, buprenorphine, outpatient detoxification medications, nicotine replacement, etc.), and in the substance abuse treatment setting, research on program evaluations of integrated programs is needed.
Just as no single diagnosis can be made that encompasses all substance abuse disorders and mental disorders, interventions need to be unique to the individual's needs. However, over the past few years, many effective practices have emerged that combine the best available research with clinical expertise to address the individual needs of persons with co-occurring substance abuse disorders and mental disorders.
For example, the evidence base is growing about the effectiveness of interventions that respond to an individual's stage of recovery and motivation to change with the focus on building a therapeutic relationship between client and clinician, and that offer services for other needs in the person's life, including the need for housing and work (Drake et al., 2001). Specific medications and specific psychosocial treatments that target specific disorders (e.g., depression, anxiety, cocaine addiction, alcohol dependence, etc.) are being combined and modified for specific combinations of substance abuse disorders and mental disorders. These integrated clinical interventions are being implemented in integrated and non-integrated programs that include a broad range of settings that include inpatient, outpatient, community-based, and residential.
Many psychosocial treatment interventions are being pilot tested. More research is needed. In addressing co-occurring disorders, the system must also help the family members to learn about the different disorders, how to be supportive, when to be firm, and how to help themselves. Family involvement is particularly critical for children. Family-based treatment providers work with adolescents, parents, parent-adolescent combinations, and whole families and include attention to the youth's environment, including peers, schools, and neighborhoods. An extensive body of clinical research shows the effectiveness of one particular model called multisystemic therapy for improving family relations, decreasing adolescent substance use, and reducing long-term rates of re-arrest and out-of-home placements (CSAP, 2001).
There is a gap between what research shows to be effective and what is practiced in the clinical setting. This gap is due to many factors, including limited financial resources. For example, many substance abuse outpatient treatment programs have no resources to pay for a medical specialist to evaluate and do ongoing management of mental disorders, and therefore the known effective interventions of psychiatric medications cannot be integrated into the program or treatment plan at that site. Another issue is the knowledge gap. The National Institute on Drug Abuse has published a monograph about evidence-based practices for drug abuse. The CSAT Treatment Improvement Protocol focusing on co-occurring disorders outlines many of the evidence-based practices for such disorders and is currently being revised to reflect new research. SAMHSA's initiative - Implementing Evidence-Based Practices for Severe Mental Illness Project - is developing toolkits to promote the delivery of effective practices at the State and local levels, including integrated treatment for co-occurring disorders.
Many approaches to treat co-occurring disorders that do not meet strict standards of evidence are nevertheless commonly accepted and believed to be effective based on the best available research, clinical expertise, individual values, common sense, and a belief in human dignity. It is incumbent on practitioners to use the best available approaches.
SAMHSA has the key Federal role in moving evidence-based and other effective practices to the field through a collaborative process and will take the lead in bringing together researchers, clinicians, and other specialists in a National Summit on Co-Occurring Disorders to share practices and lessons learned in such areas as prevention, the adoption of evidence-based practices, funding, and service systems changes.
Evidence-based practices are necessary but not sufficient to meet the multiple and complex needs of people of all ages who have co-occurring disorders. These individuals require a system-wide response.
Systemic barriers to the integration of mental health and substance abuse treatment are difficult and longstanding. These include addressing separate administrative structures, funding mechanisms, priority populations, treatment philosophies, clinician competencies, and eligibility criteria, among others. Inadequate resources for both mental health services and substance abuse treatment, and lack of staff educated and trained in co-occurring disorders treatment, are among the most significant barriers to the provision of integrated, comprehensive service systems.
An increasing number of States and communities throughout the country are initiating system-level changes and developing innovative programs that overcome barriers to providing services for individuals of all ages who have co-occurring disorders. Many make use of their Substance Abuse Prevention and Treatment and Community Mental Health Services Block Grant funds to do so, as authorized by law.
States and communities that are successful build consensus around the need for an integrated response to co-occurring disorders, develop aggregated financing mechanisms, cross-train their staff, and measure their achievement by improvements in client functioning and quality of life. Some innovative State practices are highlighted in a recent report (NASMHPD/NASADAD, 2002). Though each of the programs profiled in the report implemented different approaches, they shared important commonalties, including those noted below.
· Agency leaders created a shared vision and established a set of expectations concerning co-occurring disorders treatment that staff were encouraged, supported, and expected to follow.
· Each State created its own particular model of integrated services to respond to local needs, but they all featured comprehensive service systems capable of responding to most or all of the needs of individuals with co-occurring disorders, including co-morbid medical conditions.
· Agency staff expected their clients to present them with a full range of co-occurring symptoms and disorders (emphasis in original). They screened and assessed for related conditions, including HIV/AIDS, physical and/or sexual abuse, brain disorders, physical disabilities, etc.
· Staff were cross-trained in both mental health and substance abuse disciplines; however, they did not work outside their field of expertise. Many clinicians now realize the value of developing the credentials to treat both the substance abuse disorders and mental disorders. They delivered care as part of a multidisciplinary team that featured shared responsibility for clients and was culturally appropriate.
· Services were client-centered. Staff engaged with individuals who were at various stages of acceptance and recovery. They expressed hope for their clients' success in treatment and empowered their clients to do the same.
SAMHSA will lead the national effort to ensure accountability, capacity, and effectiveness in the prevention, diagnosis, and treatment of co-occurring substance abuse disorders and mental disorders. The Agency's Five-Year Blueprint for Action to address co-occurring disorders will guide this effort.
SAMHSA's mission is clear. The Agency will enhance its leadership to create systems that put people first. It will provide incentives including training, technical assistance and discretionary funds to increase integrated substance abuse and mental health approaches in both settings and encourage the appropriate integration of medication and psychosocial treatment approaches. These actions will support co-occurring capacity enhancement by developing performance measures based upon prevention, screening, assessment, treatment, training and evaluation.
By ensuring that States and communities have the needed incentives through technical assistance and training, attention will be given to promoting provider and system accountability, enhancing system capacity, and to ensuring more effective coordination of services to address co-occurring disorders. To this end, SAMHSA will, for example:
· Strengthen the Agency's role in moving evidence-based practices to the field through a collaborative process with Federal partners, consumers/recovering persons, family members, faith-based and community organizations, providers, researchers, advocates, and State, tribal and local authorities.
· Support a new State Incentive Grant for Co-Occurring Disorders to help enhance States' supporting infrastructure and treatment system capacity. The focus of grant activities will be on the implementation of timely and accurate assessment of both the substance abuse disorders and mental disorders; the creation of a system in which "any door is the right door" to receive needed services for co-occurring disorders; and the expectation that States will select one or more of three capacity expansion goals - screening, assessment, and treatment. Increased service capacity is an expected program outcome.
· Demonstrate leadership in ensuring development of a workforce educated and trained to address co-occurring disorders. For example, the purpose of the fiscal year 2003 planned National Co-Occurring Disorders Prevention and Treatment Technical Assistance and Cross-Training Center is to develop, coordinate, and provide, on a national scale, cross training to mental health, substance abuse, education, homeless, criminal justice, and primary care providers.
· Direct the Agency's Minority Fellowship Program (MFP) to focus on co-occurring disorders. The MFP is the only Federal program providing funding to increase the number of racial and ethnic minorities entering the Nation's mental health and substance abuse workforce.
· Provide grant, technical assistance and training to help States develop/enhance co-occurring State capacity building in prevention, screening, assessing, treating, training and evaluating for co-occurring substance abuse disorders and mental disorders.
· Continue SAMHSA's work with the Health Resources and Services Administration (HRSA), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), NASMHPD, NASADAD, the National Alliance of State and Territorial AIDS Directors (NASTAD), State Public Health Organizations and other State representatives, and community-based providers to develop States' capacities to enhance the integration of services for HIV/AIDS, substance abuse disorders, and mental disorders.
· Expand SAMHSA's partnership with its colleagues at the National Institutes of Health (NIH), including the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute of Alcohol Abuse and Alcoholism (NIAAA), as well as the Agency for Healthcare Research and Quality. As the development of the science-to-services partnership agenda is a two-way process in which research informs services, and services inform research, the agenda's development includes enhancing research attention to co-occurring disorders and the field's research needs. Areas to be discussed include research on the NASMHPD/NASADAD quadrants, and on appropriateness of integrated interventions, programs and systems of care.
· Strengthen the Agency's relationship with the Centers for Medicare and Medicaid Services (CMS) and AHRQ. In particular, explore ways to utilize existing reimbursement mechanisms for the assessment, diagnosis and treatment of people with co-occurring substance abuse disorders and mental disorders. Further, SAMHSA will provide State Medicaid directors and mental health and substance abuse authorities with information on how co-occurring disorders can be addressed within their respective Medicaid plans.
· Disseminate successful strategies for appropriate use of the SAPT and CMHS Block Grants to serve individuals with co-occurring disorders, compliant with Section 1956 of the U.S. Public Health Service Act. This will occur, in part, by supporting State-to-State peer technical assistance by States that have implemented recognized, statewide, system-level changes for co-occurring disorders.
· Convene a National Summit on Co-Occurring Disorders. Summit participants will include SAMHSA's Federal partners, consumers/recovering persons, family members, faith-based and community organizations, providers, researchers, advocates, and State, tribal and local authorities. Among the expected outcomes are identification of current incentives that bounce individuals between systems, gaps in the substance abuse and mental health treatment/service systems, and recommendations to address identified issues.
· Continue to improve, refine, test, and apply consistent outcome measures for co-occurring disorders. This action is consistent with the Performance Partnership requirements of SAMHSA's 2000 reauthorization and will build on the significant work in performance measurement conducted to date by NASMHPD and NASADAD, in collaboration with SAMHSA.
· Examine the complex issues regarding the use of psychoactive medications to treat mental disorders for individuals who also have co-occurring substance abuse disorders, looking toward the creation of a robust research base on which to make sound clinical judgments in this area.
The collaborative process involved in developing this report to Congress is a major step in the right direction, but it is only a beginning. Over the next 5 years, SAMHSA will take the lead in helping States, tribes, and communities promote accountability, capacity, and effectiveness in prevention, early identification and intervention, and treatment for co-occurring substance abuse disorders and mental disorders.
The goal is simple: to improve outcomes for individuals of all ages who are at risk for or who have a full range of co-occurring disorders. This means addressing alcohol, tobacco, and other drugs, and a wide range of mental disorders, in both the substance abuse and mental health treatment systems. This will occur by initially improving access and an initial evaluation at any door - "any door is the right door." SAMHSA will promote the development of seamless systems of prevention, early identification and intervention, treatment, and follow-up care. The Agency will forge collaboration and cooperation among its Centers for Substance Abuse Treatment, Substance Abuse Prevention and Mental Health Services and across all key constituencies. Staff training, technology transfer, use of evidence-based practices, and the development of new research programs to address the problem of co-occurring disorders will be enhanced and strengthened.
Ultimately, this report to Congress is a call to action for all whose lives are touched by people who have co-occurring substance abuse disorders and mental disorders. SAMHSA is acting on what is known and will continue to learn and promulgate the best ways to prevent and treat these serious and potentially disabling conditions. Children, adolescents, adults, and older adults deserve nothing less.
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