Section 3: Status of Mental Health Services at the Millennium

Chapter 10. Co-occurring Addictive and Mental Disorders

Fred C. Osher, M.D.

Center for Behavioral Health, Justice, and Public Policy and University of Maryland School of Medicine

Introduction

Over the past two decades, concern about how best to serve persons with co-occurring mental illness and substance use disorders has steadily increased. It is estimated that up to 10 million people in the United States meet criteria for co-occurring disorders in any given year (CMHS, 1997). Public and professional attention stems from increasing awareness of two principal findings: first, the heightened awareness of the prevalence of substance abuse and dependence in persons with mental disorders and of psychiatric symptoms among persons with substance use disorders; and second, the consistent associations of poor adjustment and suboptimal outcomes among persons with co-occurring disorders. Clinicians, health care administrators, families, and consumers articulate a sense of frustration that not enough is being done to address the needs of persons with co-occurring disorders.

These groups witness the revolving-door nature of these individuals as they cycle in and out of costly and inappropriate treatment settings such as emergency rooms and jails. While significant advances have been made in our understanding of the scope of the problem and the potential effectiveness of nontraditional interventions, access to care is not available to the majority of persons with co-occurring disorders (CMHS, 1997). This paper will highlight epidemiological findings, evidence-based practices, principles of care associated with positive outcomes, and policy directions to address the needs of persons with co-occurring mental and addictive disorders.

Epidemiology

Treatment planning and policy development require an accurate description of the problem to be addressed. Despite considerable progress in assessment tools and strategies, the identification and characterization of persons with co-occurring disorders remains a difficult task. Any drug of abuse may combine with any mental disorder to produce a wide range of symptoms and disability. The degree of disability associated with these disorders will vary over time. These factors create a heterogeneous population that varies not only in presenting signs and symptoms, but also in the ways its members come to the attention of treatment systems. In reviewing epidemiological data, it is important to keep this heterogeneity in mind and not assume prevalence rates alone can inform systemic responses. Substance use disorders in clinical samples of patients with schizophrenia (Barry et al., 1995; Mueser, Bennett, & Kushner, 1995), bipolar disorder (Goodwin & Jamison, 1990), and young persons with longterm mental illnesses (Safer, 1987) reveal a wide range of prevalence estimates, from 10 percent to more than 65 percent. Variability in prevalence rates can be attributed to differences across studies in the setting in which patients are sampled, the methods used for assessing psychiatric and substance use disorders, and the demographic mix of the study sample (Galanter, Castaneda, & Ferman, 1988; Mueser, Bennett, & Kushner, 1995).

Studies of clinical samples likely overestimate the population prevalence rates because of the health-seeking bias inherent in their design. The 1992 National Longitudinal Alcohol Epidemiologic Survey (Grant, 1997), in which persons with dual diagnoses were five times more likely to seek services than singly diagnosed respondents, and similar findings in the National Comorbidity Survey (Kessler et al., 1996) support this bias. Kessler and colleagues (1996) reported that 19 percent of alcoholdependent and 26 percent of drug-dependent individuals without a co-occurring mental disorder received treatment in a 12-month period, but in the presence of a co-occurring disorder the rates increase to 41 percent and 63 percent, respectively.

Controlling for this health-seeking bias, the rate of co-occurring substance use disorders in people with mental disorders is substantially greater than is the rate of substance use disorders in the general population. The Epidemiological Catchment Area (ECA) study (Regier et al., 1990), and later, the National Comorbidity Survey (NCS) (Kessler et al., 1996) provide compelling evidence of this. The ECA assessed psychiatric and substance use disorders in more than 20,000 persons living in the community and in various institutional settings and found that persons with a psychiatric disorder, especially those with a severe mental illness, were at increased risk for developing a substance use disorder over their lifetime. For example, persons with schizophrenia were more than four times as likely to have had a substance use disorder during their lifetime than persons in the general population, and those with bipolar disorder were more than five times as likely to have had such a diagnosis.

The NCS, using a multistage, stratified probability sample of more than 8,000 noninstitutionalized U.S. citizens, also found high prevalence rates of co-occurring disorders. For example, among NCS respondents with an affective disorder, as many as 37 percent had at least one 12-month co-occurring addictive disorder. A key finding of the NCS was the temporal relationship between the onsets of the two disorders in those individuals with dual diagnoses. In the vast majority (83.5 percent) of people, the mental disorder comes first. This fact has practical implications for prevention strategies. Specific disorders, such as bipolar disorder, were demonstrated to predict subsequent vulnerability to the development of substance use disorders, suggesting that persons with these disorders should be assessed thoroughly and provided with riskreduction advice if they do not currently have a co-occurring substance use disorder. While we cannot assume a causal link between the co-occurrence of mental and substance use disorders, the repeated identification of this strong association must be considered in service system design.

Outcomes in Traditional Systems

Substance abuse among persons with severe mental illness has been associated with negative outcomes, including increased vulnerability to relapse and rehospitalization (Brady et al., 1990; Carpenter, Mulligan, Bader, & Meinzer, 1985; Caton, Wyatt, Felix, Grunberg, & Dominguez, 1993; Haywood, Kravitz, Grossman, Davis, & Lewis, 1995; Lyons & McGovern, 1989; Negrete, Knapp, Douglas, & Smith, 1986; Seibel et al., 1993); more psychotic symptoms (Carey, Carey, & Meisler, 1991; Drake, Osher, & Wallach, 1989; Osher et al., 1994); greater depression and suicidality (Bartels, Drake, & McHugo, 1992); violence (Cuffel, Shumway, & Chouljian, 1994; Yesavage & Zarcone, 1983); incarceration (Abram & Teplin, 1991; Bureau of Justice Statistics, 1999); inability to manage finances and daily needs (Drake & Wallach, 1989); housing instability and homelessness (Caton et al., 1994; Drake & Wallach, 1989; Osher et al., 1994); noncompliance with medications and other treatments (Alterman, Erdlen, LaPorte, & Erdlen, 1982; Drake, Osher, & Wallach, 1989; Miller & Tanenbaum, 1989; Owen, Fischer, & Booth, 1996); increased vulnerability to HIV infection (Cournos & McKinnon, 1997; Cournos et al., 1991) and hepatitis (Rosenberg et al., submitted); lower satisfaction with familial relationships (Dixon, McNary, & Lehman, 1995); increased family burden (Clark, 1994); and higher service utilization and costs (Bartels et al., 1993; Dickey & Azeni, 1996).

Associations between substance use disorders among persons with mental illness and negative outcomes are not consistent across studies, and establishing causality is complicated by several factors. Comparing persons with severe mental illness who abuse substances with those who do not assumes that the two groups are otherwise equivalent, and they clearly are not. In the first place, the substanceabusing patients are more likely to be young and male (Mueser et al., 1990; Mueser, Yarnold, & Bellack, 1992). They also may be different from patients who never abuse substances prior to the onset of symptoms. For example, between-group differences have been described in the age of onset of the mental disorder (Breakey, Goodell, Lorenz, & McHugh, 1974), in premorbid functioning (Arndt, Tyrrell, Flaum, & Andreasen, 1992), in premorbid sexual adjustment (Dixon, Haas, Weiden, Sweeney, & Frances, 1991), and in family history of substance use disorders (Noordsy, Drake, Biesanz, & McHugo, 1994). Finally, the association of medication and treatment noncompliance, homelessness, and other social problems with psychiatric illnesses and substance abuse may account for their poor adjustment (Drake & Wallach, 1989; Osher et al., 1994). Despite the difficulty in establishing causality, the negative outcomes associated with the presence of co-occurring disorders in traditional treatment settings suggests that nontraditional treatment approaches are required.

Evidence-based Treatment

Given the high prevalence rates and the high morbidity and mortality associated with having co-occurring disorders, the identification of effective interventions has gained both immediacy and a growing database. For the past 15 years, extensive efforts have been made to develop integrated models of care that bring together mental health and substance abuse treatment. The reported studies have focused primarily on individuals with serious mental illnesses and co-occurring substance use disorders. Recent evidence from more than a dozen studies shows that comprehensive integrated efforts help persons with dual disorders reduce substance use and attain remission (Drake, Mercer-McFadden, & Mueser, 1998). Integrated approaches also are associated with a reduction in hospital utilization, psychiatric symptomatology, and other problematic negative outcomes. Comprehensiveness was the critical component in successful interventions. Those programs that simply added a group or shortterm treatment intervention to existing programming suffered high dropout rates and had little overall impact on rates of either substance abuse or psychiatric symptomatology. Comprehensive approaches were defined by the inclusion of a staged approach to care with motivational interventions, assertive outreach, intensive case management, individual counseling, longterm interventions, and family interventions. Positive outcomes included high rates of engaging and retaining patients in care, reduced hospital utilization, reduced substance use, and increased abstinence. This research base has allowed the development of treatment principles associated with positive outcomes.

Principles of Care

Historically, mental health and substance abuse approaches to care have been different. However, principles of care within the two fields converge on respect for the individual; reaching out to engage those who cannot yet trust; and the importance of community, family, and peers to recovery. The American Association of Community Psychiatrists used the existing evidence base shaped by the experience of developing effective systems of care to develop the principles below (AACP, 2000). These serve to bridge the gap between the service orientations and characterize an effective system of care for persons with co-occurring disorders. They can be used for both planning and evaluation purposes.

Acceptance

Accessibility

In an accessible system for persons with co-occurring disorders, 24-hour crisis services are available to provide competent assessment and intervention for psychiatric and substance symptomatology in any combination. Arbitrary barriers to immediate evaluation (e. g., alcohol levels below legal intoxication) are not present.

Integration

There must be an integrated conceptual framework for designing a comprehensive service system for persons with co-occurring disorders. Treatment must address two or more interwoven chronic disorders. This can be achieved by implementing the following procedures: (1) develop a common language for describing the target population; (2) develop a common methodology for describing categories of integrated services in the system based on the respective severity or disability of the individual; (3) ensure that each disorder receives specific and appropriately intensive primary treatment that takes into account the complications resulting from the co-occurring disorders; and (4) identify a primary clinician for each individual who has the responsibility of coordinating ongoing treatment interventions for both disorders. While no specific model should assume to be generalizable across systems, the common goal should be for persons to get their needs comprehensively addressed within one setting, by one set of providers. Successful integrated efforts will reduce conflicts between providers, eliminate administrative barriers to care, and assist the patient by providing a consistent message about recovery principles (Minkoff, 1989).

Continuity

Psychiatric and substance use disorders, regardless of severity, tend to be persistent and recurrent. Co-occurrence of these disorders occurs with sufficient frequency that a continuous and integrated approach to assessment and treatment is required, regardless of the location of the initial clinical presentation. A goal of the service system is to provide persons with co-occurring disorders early access to continuous integrated treatment relationships that can be maintained over time through multiple episodes of acute and subacute treatment.

Individualized Treatment

Any psychiatric disorder with any substance use disorder may occur in any person, regardless of age, gender, or socioeconomic status. Effective responses must be tailored to the needs of the consumer, instead of consumers needing to fit the specifications of the program. Integrated, continuous treatment relationships should be developed to support the consumer with a balance of appropriate case management and care. The system should be created utilizing existing services and programs as much as possible, with matching of programs to individual needs to ensure opportunities for meaningful choice and empowerment at each point during the course of treatment.

Comprehensiveness

Persons with co-occurring disorders have broad primary care and behavioral health treatment, social service, and housing needs. Therefore, the shared mission of the system must be to provide a broad range of necessary services. Some programs within this system will be fully integrated; other programs will be primarily psychiatric with substance disorder capability or enhancement, or vice versa; and some programs will have minimal behavioral disorder expertise (e. g., housing programs) and require cross-training and collaboration.

Emphasis on Quality

The system of care should be designed in accordance with established national standards for serving persons with co-occurring disorders in public managed care systems (e. g., CMHS Workforce competencies for dual diagnosis treatment in managed care systems [CMHS, 1998]). When evidence for the effectiveness of interventions has been established, these best practices should be introduced into the system of care. The development of a standardized assessment tool across all clinical settings will enhance quality evaluation efforts. In addition, the identification of objectives or quality monitors (structure, process, and outcome) as markers for successful implementation is a critical step.

Responsible Implementation

There must be an implementation plan that identifies priorities for and barriers to change, and that recommends strategies to overcome such barriers. The plan should be derived from: (1) the identification of existing services for persons with co-occurring disorders, and specification of the role of those services in the system of care; (2) the identification of significant gaps in existing services, which require new services, programs, and/or funding to address those gaps; (3) the development of a process to modify policies, procedures, regulations, or laws in order to create flexible funding streams; and (4) the creation of an infrastructure empowered to oversee and direct the implementation process.

Optimism and Recovery

A growing evidence base suggests that persons with co-occurring disorders who receive care based on the aforementioned principles have positive outcomes. This evidence is contrary to prevailing attitudes among administrators, providers, families, and consumers. This nihilism, which serves the systems goals poorly, can be addressed through disseminating available evidence and data. Every person, regardless of the severity and disability associated with his or her co-occurring disorders, is entitled to experience the promise and hope of recovery.

Barriers and Solutions

While it is possible to identify principles of care, it is more difficult to identify the persons within the existing service systems who should be responsible for implementing these principles and engaging the person with co-occurring disorders in treatment. Persons with co-occurring disorders may seek help from mental health, substance abuse, or primary health care providers. The systems that support these providers historically have operated independent of one another with separate philosophies, administrative oversight, and financial support (Ridgely, Goldman, & Willenbring, 1990). Both public and private sector initiatives over the past 20 years have reinforced the separation of these systems (Osher & Drake, 1996) while persons with co-occurring disorders continue to flood clinical settings.

The debate surrounding appropriate models of care and the locus of responsibility for providing care is often acrimonious as administrators and policymakers struggle to stretch scarce resources over the spectrum of care required for effective treatment of "singly" diagnosed populations. Failure to resolve these barriers to care ensures that access to effective integrated care interventions is unavailable. In order to move the debate forward, there must be a shared language and vision for how to provide care to dually diagnosed individuals. One useful model was developed in New York and endorsed by both the National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors (NASMHPD & NASADAD, 1999). Rather than focus on diagnoses, the model uses two dimensions— the severity of the mental illness and the severity of the addiction— to define four subgroups of dually diagnosed individuals (Figure 1). The model then assigns responsibility to (1) primary care providers with consultation from behavioral health specialists (for persons with low severity on each dimension), (2) one of the specialty sector systems (for persons with either severe mental illnesses or severe alcohol or drug abuse) with collaboration from the other specialty sector, or (3) a set of providers providing integrated care to the most disabled consumers (Figure 2). The advantages of this model are that it encompasses the heterogeneity of the dual diagnosis population, it assigns responsibility to every system for providing some degree of care to dually diagnosed individuals, and it is flexible enough to be adapted to most service settings. Significant overlap between systems is inherent in the model and it more realistically corresponds to the multiple pathways used by dually diagnosed persons to access care.

Using a framework as outlined above can serve as the basis for State and local strategies to ensure that the needs of persons with co-occurring disorders are addressed. The appropriate domain for service delivery and the eligibility criteria for various service settings will vary depending on existing resources and programmatic structure. Various mechanisms can be used to ensure accountability and manage client flow. These mechanisms include interagency agreements, joint program development, cross-training of providers, and the specific identification of individuals with co-occurring disorders as a priority population within all strategic planning initiatives (Ridgely & Dixon, 1995). At the community and program level, Minkoff (1997) has outlined a process for implementing integrated services, starting with the development of an integrated philosophy among all relevant stakeholders— from consumers to administrators. After agreement on an integrated mission and some principles of care, an assessment of current organizational capacity is performed and service gaps are identified. Participants then prioritize modest steps toward creating a continuum of assessment and treatment services using evidence-based practices. Ongoing psychiatric and addiction training is provided to all staff. Minkoff emphasizes the importance of leadership at all levels and the utility of ongoing process and outcome evaluation.

Conclusions

The mental health and addiction fields share a history of stigma and discriminatory financing practices despite having positive outcome data on treatment effectiveness every bit as good as data on somatic health services (National Institute of Mental Health, 1993). And providing services to dually diagnosed individuals with complex bio-psychosocial needs is necessarily costly. But the fact that integrated approaches with demonstrated effectiveness for those with co-occurring disorders are not widely available cannot be solely explained on the basis of scarce resources. Not providing highquality care is ultimately more costly in terms of both dollars and quality of life.

The failure to offer more comprehensive care for persons with co-occurring disorders is a failure in clinical and administrative leadership. Progressive policies within private and public sectors can produce incentives for integrated efforts. As an example, language embedded within a small Federal assistance program for homeless persons, the Program for Assistance in the Transition from Homelessness, limits funds to those entities that agree to address the needs of dually diagnosed homeless persons in a coordinated fashion. Similar nondiscriminatory language should be included in other behavioral health service and research grants, block grants, or requests for managed care proposals. Our consumers do not have the opportunity to separate their addiction from their mental illness, so why should we do so administratively and programmatically?

Principles of care within mental health and addiction fields converge on respect for the individual, belief in the human capacity to change, and the importance of community, family, and peers to the recovery process. There is far more to be gained by an alliance between these entities than sustaining the current divisions. The 10 million citizens with co-occurring disorders deserve no less.

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