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.
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.
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:
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.
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.
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.
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.
The rationale for developing best practice guidelines for the treatment of concurrent disorders is grounded primarily in three areas of research and clinical experience:
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:
It is recommended that:
It is also recommended that:
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.
Co-occurring substance abuse and mood and anxiety disorders:
Co-occurring substance abuse and severe and persistent mental illness:
Co-occurring substance abuse and personality disorders:
Co-occurring substance abuse and eating disorders:
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.
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.
In synthesizing the information and themes, the following list of alternative strategies may support system-level integration: