Best Practices - Concurrent Mental Health and Substance Use Disorders

Executive Summary

Background, Definitions and Approach

Over the last two decades the co-occurrence of addiction and mental health problems among people seeking treatment and support has emerged as an important issue for those who plan and fund mental health and substance abuse programs, as well as for those who provide direct service. Concerns about concurrent disorders have been fueled by research showing the high prevalence of such co-morbidity and its implications for the course, cost and outcome of treatment and other support services.

The present project provides an updated synthesis of the research information and offers specific recommendations for the screening, assessment and treatment/support of this in-need population based on the highest quality research information that is available. The research synthesis has been combined with the advice and input of experts and other key stakeholders in the field, including consumers who have experienced the severe consequences of concurrent disorders. This synthesis is best seen as complementing the considerable amount of work that has preceded the project and the reader is encouraged to examine the key resource material drawn upon (Appendix A).

A national inventory of specialized concurrent disorders programs, entitled "National Program Inventory - Concurrent Mental Health and Substance Use Disorders" has also been developed and is published separately as a companion to this document.

Intended Audience

This report is intended to be a resource to managers and staff of mental health, substance abuse and integrated mental health/substance abuse services, as well as individual practitioners in the community who are faced with the challenges of providing good quality service to people presenting with concurrent mental health and substance use disorders. In addition, the report is targeted at planners, community developers and other decision-makers that work at a more systems level. Researchers and program evaluators will also benefit from this synthesis.

Defining Concurrent Disorders

In general terms, the concurrent disorders population refers to those people who are experiencing a combination of mental/emotional/psychiatric problems with the abuse of alcohol and/or other psychoactive drugs. More technically speaking, and in diagnostic terms, it refers to any combination of mental health and substance use disorders, as defined for example on either Axis I or Axis II of DSM-IV.

Substance use disorders is the diagnostic term that refers to a habitual pattern of alcohol or illicit drug use that results in significant problems related to aspects of life such as work, relationships, physical health, financial well-being, etc. There are two mutually exclusive subcategories - substance abuse and substance dependence (see Appendix B). In some cases, the use of substances per se (as distinct from abuse or dependence) negatively impacts people with mental health problems.

To people working in the substance abuse field using the DSM-IV as the basis for the definition of concurrent disorders may appear to be an overly medical and psychiatric approach. This approach, however, is the most widely used in the research literature on concurrent disorders, and it has been used in previous attempts to define best practices in this area. This practice is continued because:

• appropriate treatment and support in the mental health field, including drug therapies, comes after accurate assessment and diagnosis. It follows then that the same holds true for people with concurrent mental health and substance abuse problems;
• a mental health diagnosis based on DSM can be established by some 'non-medical' professionals, such as registered psychologists;
• a broad psychosocial rehabilitation approach is now widely regarded as essential for effective care and support of people with mental health problems. In the same vein, the treatment and support of people with concurrent disorders goes well beyond strictly medical/psychiatric interventions.

Acceptance of the medical/psychiatric framework underlying the DSM, or other mental health classification systems, may at times be one of the challenges that substance abuse workers and planners may need to overcome in bridging the worlds of mental health and substance abuse. It is also recognized that this option for classification may need to be adapted somewhat in those communities that do not have access to professionals who are qualified to make mental health diagnoses.

Recommended Approach to Classification

Over the past two decades, the term dual diagnosis was most commonly employed for the combination of mental health and substance use disorders. This term, however, also applies to co-existing psychiatric disorders and developmental disabilities. Other terms and acronyms that may be encountered will be CAMI (chemically abusing - mentally ill), or MICA (mentally ill - chemically abusing), or SAMI (substance abusing-mentally ill). The term concurrent disorders is preferred since it retains the emphasis on appropriate diagnosis as a guide to planning treatment and support, and distinguishes this area from other important work in the field of developmental disabilities and mental health. Thinking of mental health and substance use problems as a plurality, rather than a duality, is more consistent with the typical clinical presentation of the abuse of multiple drugs, including alcohol, and often more than one psychiatric diagnosis.

Clinicians and support workers need guidelines that will be helpful in dealing with specific types of concurrent disorders. Given the early stage of research that is both substance- and diagnosis-specific, sub-categories that make intuitive sense can be developed on the basis of clinical experience and the most common combinations of mental health and substance use disorders that present among the people seeking treatment and support. The following five sub-groups within the broad group of concurrent disorders are recommended:

Group 1: Co-occurring substance use and mood and anxiety disorders;

Group 2: Co-occurring substance use and severe and persistent mental disorders;

Group 3: Co-occurring substance use and personality disorders;

Group 4: Co-occurring substance use and eating disorders;

Group 5: Other co-occurring substance use and mental health disorders.

This report focuses on the first four groups.

Defining Integrated Treatment

A distinction between "program integration" and "system integration" is proposed to reflect innovations under way to improve care and support across treatment units or community agencies. Program integration means:

mental health treatments and substance abuse treatments are brought together by the same clinicians/support workers, or team of clinicians/support workers, in the same program, to ensure that the individual receives a consistent explanation of illness/problems and a coherent prescription for treatment rather than a contradictory set of messages from different providers.

System integration means:

the development of enduring linkages between service providers or treatment units within a system, or across multiple systems, to facilitate the provision of service to individuals at the local level. Mental health treatment and substance abuse treatment are, therefore, brought together by two or more clinicians/support workers working for different treatment units or service providers. Various coordination and collaborative arrangements are used to develop and implement an integrated treatment plan.

As with program-level integration, treatment plans that cross service providers may involve addressing the substance abuse and mental health disorders either concurrently or sequentially, but always in the context of a consistent and coordinated approach tailored to the unique needs and capacities of the individual.

Need for a Broader Psychosocial Perspective

Finally, with respect to the term integrated treatment, some comments are offered about the use of the word treatment in this context. In the mental health field, the focus on community integration for people with severe mental illness has been a dominant force over the past two decades. Coincident with this trend has been a shift toward a broad psychosocial rehabilitation perspective. This broader perspective values the critical role of acute treatment, medication management and symptom reduction in creating more long term positive outcomes. It also advocates for supporting the person in a wide variety of areas, including housing, employment, recreation and social networks, to name just a few. As a result of new thinking about community integration and specific policy initiatives that have supported the paradigm shift, a wide array of community support programs has emerged. This includes services that are consumer-run and which bring an experiential perspective to service delivery and support. The goals of these support services are broadly stated as helping persons with severe mental illness become reintegrated into the community, and improving their quality of life and that of their families.

These psychosocial support services are recommended as part of the overall package of care and support for people with severe mental illness (e.g. schizophrenia practice guidelines). Therefore, it must be emphasized that they also have a clear role in an integrated program or system for people with concurrent disorders, if they are required by the person on the basis of their needs and functional abilities. Although this is consistent with the advice of several experts in the field, it may not be immediately obvious given the use of the term integrated treatment. Thus, the term integrated treatment and support is preferred as it is more consistent with this broader psychosocial rehabilitation perspective.

Rationale For Best Practice Guidelines

The rationale for developing best practice guidelines for the treatment of concurrent disorders is grounded primarily in three areas of research and clinical experience:

• the prevalence of co-morbidity is high in the general and treatment-seeking populations and has largely been ignored in planning, implementing and evaluating both mental health and substance abuse services;
• substance abuse and mental health co-morbidity changes the course, cost and outcome of care and presents significant challenges for screening, assessment, treatment/support and outcome monitoring;
• substance abuse and mental health services in the community have typically worked in isolation and often from competing perspectives.

Best Practice for Concurrent Disorders at the Service Delivery Level

There are many entry points into a community's mental health and substance abuse systems. While people with concurrent disorders may be more likely to show up at some entry points than others (e.g., emergency and crisis services, homeless shelters), the research data would suggest that the prevalence of concurrent disorders will be high across all entry points. It is also important to note that in the mental health system, the duration of time with which a person with a concurrent substance use disorder is being treated or supported by a particular program is quite variable, ranging from very brief contact at a crisis service, to a few weeks or months in an acute treatment setting, to several years of regular contact and support through a community team, a supported housing program, a clubhouse or a consumer survivor initiative. Similarly, across substance abuse services in the community the opportunities for identifying someone with a mental health disorder are quite different in different settings (e.g., brief contact at a withdrawal management centre compared to several weeks or months of support from an outpatient or residential treatment program). In addition, the types of professional training, experiential knowledge and perspective also differ substantially across these settings. These factors will impact on managers, staff and consumers when initiating various strategies that might be recommended for identification, assessment and treatment/support. The role of the family/significant others will also be highly variable, for example, in providing collateral reports of substance abuse, or participating in family systems interventions. These important contextual factors notwithstanding, there is a need for evidenced-based advice in three areas:

1. Identifying if someone has a potential substance use disorder or mental health disorder (depending on the setting).
2. For those screened positive, conducting a comprehensive assessment that will investigate more conclusively the nature and severity of the substance use or mental health problem and how they are related. In areas with limited resources this step may out of necessity also include referral to another service for support in assessing the substance use or mental health problem, but this referral is made in the context of a coordinated system of local services, with follow-up to ensure an integrated treatment plan is developed.
3. For those determined to have a concurrent substance use disorder and mental health disorder on the basis of the assessment, providing treatment/support for the immediate problem resolution, and providing longer term monitoring, support and rehabilitation. As above, in some communities this step may also include referral to another service for support with the substance abuse or mental health problem but this needs to be done in the context of an integrated treatment plan, and a coordinated system of local services.

Screening

It is recommended that:

• all people seeking help from substance abuse services be screened for co-occurring mental health disorders. The advice is organized around Level I and Level II approaches that are tailored to the type of setting and time and resources available.

It is also recommended that:

• all people seeking help from mental health services be screened for co-occurring substance use disorders. The advice is organized around Level I and Level II approaches that are tailored to the type of setting and time and resources available.

Assessment

On the basis of a positive screen for either substance use or mental health disorders, it is recommended that a comprehensive assessment (a) establish diagnoses (b) assess level of psychosocial functioning and other disorder-specific factors and (c) develop a treatment and support plan that tries to sort out the interaction between the mental health and substance use difficulties for the individual, and work toward a positive outcome for both sets of problems.

Treatment and support

Co-occurring substance abuse and mood and anxiety disorders:

• an integrated approach to treatment/support is recommended;
• with the exception of post-traumatic stress disorder, and in the context of an integrated approach, a sequencing of the specific intervention (beginning with the substance abuse) is recommended, accompanied by ongoing assessment and adjustment of the treatment/support plan if the mood and anxiety disorder does not improve following an improvement in the substance use disorder;
• for post-traumatic stress disorder an integrated treatment approach that deals with both the post-traumatic stress disorder and substance abuse at the same time is recommended;
• the best current evidence for the treatment of concurrent mood and anxiety disorders, including post-traumatic stress disorder, is cognitive behavioural treatment.

Co-occurring substance abuse and severe and persistent mental illness:

• an integrated approach to treatment/support is recommended;
• within this integrated approach, it is recommended that interventions for substance abuse and severe mental illness be planned and implemented concurrently;
• the best current evidence is for a range of services that includes a staged approach to engagement and service delivery; outpatient setting; motivational interviewing and cognitive-behavioural treatment; harm reduction and comprehensive psychosocial rehabilitation supports, to name a few program/system components.

Co-occurring substance abuse and personality disorders:

• an integrated approach to treatment/support is recommended;
• within this integrated approach, it is recommended that interventions for substance abuse and borderline personality disorders be planned and implemented concurrently;
• evidence on the treatment of antisocial personality disorder and substance use disorders suggests addressing the substance use problem first
• the best empirically supported treatment for borderline personality disorder and substance use disorders is dialectical behaviour therapy (DBT), which includes behavioural skills training.

Co-occurring substance abuse and eating disorders:

• an integrated approach to treatment/support is recommended;
• within this integrated approach, it is recommended that interventions for substance abuse and the eating disorder be planned and implemented concurrently unless there are compelling clinical reasons, such as life threatening factors, for focusing on one of the disorders first;
• the most promising intervention is a combination of medical management, behavioural strategies to effect change in the eating and substance abuse behaviour, and psychotherapy to address psychological issues.

Implications of Best Practice Guidelines at the System Level

Ryglewicz and Pepper³⁴ provide a helpful historical perspective on the increase in the number of people in the community with concurrent disorders. They note the historical separation of three very distinct clinical populations - mental patients, alcoholics and drug addicts. The former were in psychiatric institutions. Alcoholism was not seen as a problem until well along its course and, if treated at all, it was in highly specialized treatment facilities. Drug addiction was seen as confined to a small segment of society and viewed largely in a criminal context. These times have vanished. The shift has come primarily from the de-institutionalization of mental health services; the corresponding movement towards community support for people with severe mental illness⁷³; and the increasing availability of drugs in the community since the 1960s. So rather than the three formerly separate clinical populations, we now have large groups of people in the community with overlapping and interacting mental health and substance use problems. The difficulty from the service delivery perspective is that community agencies, planners and policy makers have been stuck in the single-problem mode of thinking because of the long established barriers between the treatment systems for mental health and substance abuse. The barriers came about as a result of separate training and development in the two fields, which became entrenched in separate funding, administrative and policy structures. An additional barrier is the perceived complexity, uncertainty, and level of difficulty associated with a more integrated approach. Taking an historical perspective on the emergence of the two systems helps to better understand the problems being faced by consumers who currently need to cross over the two systems.

A Less Prescriptive Approach at the System Level

Canada is just at the beginning stages of developing and trying out various strategies to better integrate services at the system level. There is very little published information that goes beyond an assessment of the many challenges and barriers to systems integration, to actual implementation and evaluation of different concrete strategies. In general, the current state of knowledge and practice wisdom is not sufficiently developed to offer best practice recommendations at the system level, so the discussion is more descriptive than prescriptive.

A Shopping List of Alternatives to Support System Integration

In synthesizing the information and themes, the following list of alternative strategies may support system-level integration:

• it is critical that people with concurrent disorders and their family members be meaningfully involved in planning and system development activities;
• given the pace of knowledge development and the extent to which innovative solutions are being explored there is a need for a mechanism to share information and lessons learned. A possible vehicle to achieve this would be a Canadian-based web site and potentially a national Concurrent Disorders Resource Centre that would support research dissemination and knowledge transfer;
• training and education must be the centrepiece of concurrent disorders program and system development. This includes cross-training, continuing education, formal curricula development and credentialing;
• a healthy mix of top-down commitment from funders, senior administrators and Executive Directors and bottom-up exploration of linkages by front- line staff based on individual cases is suggested;
• developing a joint inter-agency planning committee is a viable option to start the local system integration process with reasonable goals and time frames in order to maximize the chance of success and build motivation to continue the change process. There may be considerable value to a staged approach starting, for example, with informal coordination activities and information sharing; to perhaps a cross-training program and then to service agreements for assessment and treatment/support. It is important that there be a dedicated resource person to support the planning and development process. It is also important to recognize that due to the complexity of integration across systems, the change process must be seen as evolutionary, non-linear and requiring time and patience;
• there is a need for clinical case consultation, including a potential role for telepsychiatry to support program and system integration in rural and remote areas;
• shared data systems that cross mental health and addictions should be explored and pilot tested;
• widespread adoption of blended service delivery teams which include a substance abuse counselor;
• formal inter-agency partnerships can be developed which go beyond joint planning exercises to the level of service agreements or potentially merged organizations;
• central access models are often recommended in both mental health and substance abuse reform processes. There is likely value in developing improved access models, including basic information about services and supports that are available, and which span substance abuse and mental health;
• policy initiatives can be undertaken at the funding level which would support integrated services and systems and provide a mechanism for demonstration projects.

Implications for Research

• there is wide variation in the level and content of integrated treatment at the program level. More research is needed on the effectiveness and cost-effectiveness of various interventions for many of the sub-groups within the concurrent disorders population, as well as fidelity measures to assess the nature and level of integration;
• there is wide variation in the level and content of integrated treatment at the system level. More research is needed on the impact of these system-level interventions on access to treatment and support, engagement and retention in the system, and the effectiveness and cost-effectiveness of various interventions for each of the sub-groups within the concurrent disorders population. Research should also investigate the value of fidelity measures to assess the nature and level of system integration; and urban/rural differences;
• two clusters of concurrent disorders were omitted from these best practice guidelines due to a lack of research evidence - concurrent disorders and sexual disorders, and concurrent disorders and pathological gambling. More research is needed in these areas;
• more research is needed on treatment/support for specific combinations of psychoactive substance use disorders (e.g., cocaine) and specific mental health disorders (e.g., depression)
• more research is needed on the link between substance use disorders and anger disorders that are independent of antisocial personality disorder;
• more research is needed on the link among dysfunctional parenting, child abuse and co-occurring mental health and substance use disorders;
• brief, validated measures are needed that would screen for mental health disorders among people seeking treatment for substance use disorders.