SAMHSA logo Report to Congress - Nov 2002








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



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The human, social, and economic costs of co-occurring substance abuse disorders and the continuum of mental disorders take a toll on the individual experiencing them, the family, the school, the workplace, the community, the State and, ultimately, the Nation as a whole.

Co-occurring disorders - defined as, "where an individual has at least one mental disorder as well as an alcohol or drug use disorder" (Center for Substance Abuse Treatment (CSAT), in press) - affect millions of Americans each year.

Congress has called on the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, as the lead Federal mental health and substance abuse services agency, to prepare a report outlining the scope of the problem, current treatment approaches, best practice models, and prevention efforts. This report, required under Section 3406 of the Children's Health Act of 2000 (Public Law 106-310), Section 503A of the Public Health Service Act (see Appendix I) is mandated to include:

a summary of the manner in which individuals with co-occurring disorders are receiving treatment, including the most up-to-date information available on the number of children and adults with co-occurring disorders, and the manner in which Federal Block Grant funds are used to serve these individuals;

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 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.

Underlying Principles

Services and programs focused on substance abuse disorders and mental disorders - whether experienced as co-occurring disorders or not - are driven by a number of key principles or precepts. First and foremost is the simple fact that people of all ages who have co-occurring disorders are people first, fully deserving of respect.

At the same time, consumers, recovering persons and their families need to be involved in all aspects of their treatment and recovery.

People with co-occurring disorders can and do recover. Everyone must be optimistic about their prospects for achieving stability and recovery, and provide the long-term support they need to maintain their progress.

People with co-occurring disorders deserve access to the services they need to recover. To put these beliefs into practice, the development of this report has been guided by the following principles:

Ensure development of a system in which "any door is the right door" to receive treatment for co-occurring disorders. This means that people with co-occurring disorders can enter any appropriate agency in the service system and be provided or referred to appropriate services.

Develop client-centered, individualized treatment plans based on an accurate assessment of the person's condition and the degree of service coordination he or she requires. Family members must be involved in treatment, where appropriate.

Ensure the maximum feasible degree of integration for individuals with the most serious substance abuse disorders and mental disorders.

Provide prevention and treatment services that are culturally competent, age, sexuality and gender appropriate and that reflect the diversity in the community.

Promote the expansion and enhancement of service providers' capabilities to treat individuals of all ages who have co-occurring substance abuse disorders and mental disorders.

Finally, this report is not recommending the creation of a separate system of care for people who have co-occurring substance abuse disorders and mental disorders. Indeed, people with co-occurring disorders must be able to receive their treatment in mainstream systems of care that are well-prepared to support their recovery, consistent with the expectations established by President Bush through the New Freedom Initiative.

The formation of partnerships should be developed at all levels, from the national to the community and the neighborhood, for developing/enhancing seamless systems of care that allow people to move freely between and among the entire constellation of services they require.

Preparing the Report

To guide the development of this report to Congress, the SAMHSA National Advisory Council's Subcommittee on Co-Occurring Disorders convened a panel of distinguished experts representing national, State, tribal, and local consumers/recovering persons, providers, State mental health and substance abuse authorities, researchers, and advocates to offer research, data, and editorial comments. Guidance and opinion was solicited from experts in related fields, including homelessness, housing, criminal justice, social services, education, aging, primary care, public and private hospitals, and health plans.

An internal SAMHSA Work Group, with representatives from each of SAMHSA's three Centers - the Center for Mental Health Services (CMHS), the Center for Substance Abuse Treatment (CSAT), and the Center for Substance Abuse Prevention (CSAP) - and the Office of Policy, Program, and Budget (OPPB), helped guide the writing process leading to this report. A list of panel members, the members of SAMHSA's Subcommittee on Co-Occurring Disorders, and the members of the internal SAMHSA Work Group are found at Appendix VII.

Constituents were invited to attend one of four meetings at which verbal input was gathered (SAMHSA, 2002b). These were held as follows:

Constituent meetings on March 11 and March 12, 2002, which gathered representatives of State substance abuse and mental health authorities and their national membership organizations; national, State, tribal, and local provider, advocacy and consumer/recovering person groups; researchers; private and public payers; and representatives from national and State primary healthcare, housing, criminal justice, education and other key non-behavioral health organizations.

Federal Partners meeting on April 15, 2002, which gathered administrators and researchers within other agencies of the U.S. Department of Health and Human Services (HHS), including the National Institutes of Health (NIH), the Centers for Medicare and Medicaid Services (CMS), the Administration on Aging; and other Federal departments, such as the Departments of Education, Justice, and Veterans Affairs.

Co-occurring Consumers, Recovering Persons, and Their Families meeting on May 1, 2002, which gathered individuals with histories of co-occurring disorders to enhance input from the March 11 and March 12 meetings.

In addition, a notice was published in the Federal Register on March 6, 2002 that invited the public to comment on issues related to the prevention, identification, and treatment of co-occurring substance abuse disorders and mental disorders. (See Appendix VI for a copy of the notice.)

Finally, the best and most current research was surveyed, investigators were interviewed, and the input was analyzed. Most important, the vast amount of input SAMHSA received enhanced the dialogue about co-occurring disorders to guide this work. The message this Agency received and continues to receive is clear and consistent: Improving the Nation's public health demands prompt attention to the problem of co-occurring disorders.

The report's "Blueprint for Action" is SAMHSA's five-year action plan for addressing co-occurring disorders and all the attendant issues and barriers to care faced by individuals with these disorders. It will guide specific actions to be taken by Federal, State and local officials in establishing and strengthening treatment and prevention services for people with co-occurring substance abuse disorders and mental disorders and seeing to their recovery. Consistent with the President's New Freedom Initiative, the Blueprint will help to ensure that those with co-occurring disorders have the supports they need to reside in, and have a meaningful life as part of, their communities.

As SAMHSA Administrator, I am firmly committed to helping people with co-occurring substance abuse disorders and mental disorders achieve recovery and full participation in American society.

Finally, a personal note regarding a tireless advocate on behalf of individuals with co-occurring substance abuse disorders and mental disorders; Max Schneier, J.D., passed away on June 17, 2002. He was appointed to the first SAMHSA National Advisory Council and served with dedication as the Council's first chair of the Subcommittee on Co-Occurring Disorders. Shortly after his death, the current Council passed a resolution acknowledging his important work in view of the enormous toll that co-occurring disorders are taking on the lives of individual Americans, their families, and their communities. I join our National Advisory Council in praising the life of this determined, steadfast and effective advocate for people with co-occurring disorders.

Charles G. Curie, M.A., A.C.S.W.


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