Best Practices - Concurrent Mental Health and Substance Use Disorders

Implications of Best Practice Guidelines at the System Level

Historical Perspective and Current Status

Ryglewicz and Pepper³⁴ provide a historical perspective on the rapid increase in the number of people in the community with concurrent disorders over the last 20-30 years. 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 with the shift coming primarily from the de-institutionalization of mental health services; the corresponding movement towards community support for people with severe mental illness;⁷³ and the increasing availability of drugs in the community since the 1960's. So rather than the three formerly separate clinical populations there are now 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 of care and support for people with mental health and substance use disorders helps to better understand the problems being faced by consumers who currently need to cross over the two systems. Placing things in an historical perspective also helps us understand the current status of efforts to improve on the situation at both the service delivery and system levels. At both levels, the barriers across the two systems are being eroded ever so slowly. Some provinces/ territories are now in various stages of merging their mental health and substance abuse services.

Similarities across the two systems

Planners, policy makers and service providers in the fields of mental health and substance abuse in Canada are finding themselves on common meeting ground. Examples include, but are not limited to:

• the acceptance of a broad bio-psychosocial model for mental health and substance use problems, and the need for a continuum of care which recognizes the value of many different types of services;
• the legitimate role of self-help organizations in both sectors and, in particular, the emergence of the consumer survivor movement in the delivery of mental health services. This shift counterbalances professional perspectives and training with lived experiences which give high priority to more basic needs of food, shelter, clothing, work, friendship, etc.;
• the increasing role of pharmacologic therapy in the treatment of substance use and advances in genetic research in both fields;
• the growing recognition of family members and significant others both as a group in need of services themselves, and as a critical support in developing and implementing an individual's care and support plan;
• the extent to which both mental health and substance abuse treatment services are linked to the correctional system and other issues related to formal and informal social control;
• the significant role of stigma in both fields, not only as a factor influencing help seeking and outcome, but also as part of the community context that calls for advocacy and public education;
• the potential for common, or at least converging, outcome indicators and other performance measures;
• the increasing recognition of the overlap in the population needing help and expressed needs of consumers for better continuity of care within and across the respective systems.

Despite the many areas of common ground that have emerged in recent years between the addiction and mental health systems, including the merging of the two systems at the provincial, department level, in some provinces, significant challenges remain in the development of integrated care and support for people with concurrent disorders.

A Less Prescriptive Approach at the System Level

In Canada and elsewhere we are just at the beginning stages of developing and trying out various strategies to better integrate services at the systems 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, however, the current state of knowledge and practice wisdom is not sufficiently developed to offer best practice recommendations at the system level.

There were two complementary components to this project - focus groups with consumers and a survey of key informants. In each component, the focus was the system-level implications for the best practice guidelines.