Conference Panel: Improving Outcomes
By Rebecca A. Clay
A farm scene was probably the last thing conference participants expected to see at
a session on "Improving Outcomes Through Organizational and Policy Change."
But to Harold Alan Pincus, M.D., a professor and Executive Vice Chair of the Psychiatry
Department at the University of Pittsburgh School of Medicine, the image's depiction
of silos perfectly illustrated the lack of integration between mental health and substance
abuse systems. "Silo-ization" is one of the biggest barriers to integrating
services for co-occurring disorders, said Dr. Pincus, who is also a senior scientist
at the RAND Corporation and Director of the RAND-University of Pittsburgh Health Institute.
Administrative obstacles include separate funding streams, different licensing and
credentialing requirements, and an overall scarcity of resources that leads to increased
competition. Clinical obstacles include the dearth of empirical data, confusion about
appropriate roles, and the fact that one condition can exacerbate the symptoms of another
and prevent successful engagement in treatment.
Important philosophical differences also exist between the two communities. Substance
abuse treatment providers are often reluctant to allow psychotherapeutic medications
for individuals with mental illness. On the other hand, mental health treatment providers
often require individuals to be both alcohol- and drug-free as a condition for entry
into treatment.
But there is hope, said Dr. Pincus, citing SAMHSA's Report to Congress on the
Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders,
the Agency's State Incentive Grants for Treatment of Persons with Co-Occurring Substance
Related and Mental Disorders, and the creation of a Co-Occurring Center for Excellence
(see 4 Million Have Co-Occurring Serious Mental Illness, Substance
Abuse).
Audrey Burnam, Ph.D., of RAND then described how state mental health, substance abuse,
and Medicaid authorities are tackling the problem of co-occurring disorders.
Summarizing the results of a 23-state study, she said that all made broad efforts
to build consensus and cross-train workforces. Some states already had changed regulations
or policies to facilitate integration, such as adapting reimbursement rules, modifying
licensing requirements, and setting standards for provider competence.
Katherine E. Watkins, M.D., M.S.H.S., a natural scientist in the health program at
RAND, summarized a literature review of evidence-based practices for those with substance
use disorders and affective or anxiety disorders.
Surveying documents produced between 1990 and 2002, the researchers noticed two broad
shifts in thinking. While earlier publications urged providers to treat substance abuse
before tackling any mental health problems, current guidelines emphasize the importance
of simultaneous treatment. In addition, guidelines now view psychiatric medications
as an important part of treatment for those with co-occurring conditions.
Robert Drake, M.D., Ph.D., Vice Chair for research in the psychiatry department at
Dartmouth Medical School, then reviewed the data for people with more severe mental
illness and less severe substance abuse, a category of co-occurring conditions that
has been more extensively studied than others.
There is plenty of evidence—29 controlled studies so far—to show that
integrated treatment does work, according to Dr. Drake.
Although it's still not clear which specific interventions work best, researchers
have identified several key components of integrated treatment:
Persons should receive individualized treatment from a clinician or team
able to address both mental health and substance abuse disorders. Treatment should proceed in stages. Providers should first engage individuals
in treatment, provide therapy designed to motivate them to change, and only then provide
active treatment. -
Treatment providers should also address other problems individuals face, such
as housing, jobs, and family issues.
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