Best Practices - Concurrent Mental Health and Substance Use Disorders

Defining Integrated Treatment

Integrated treatment for people with concurrent disorders arose in the early 1980's as a solution to the difficulties and poor outcomes associated with treatment and support being provided across the two separate systems of mental health and substance abuse services. Given the pivotal role that this term plays in the research literature, and our subsequent best practice recommendations, it is important that it be defined early in this report.

Drake et al.⁶⁴ succinctly describe the developmental history of integrated treatment in a recent review. Most of the other major reviews of treatment models for concurrent disorders also include a definition and description of integrated treatment, typically in contrast to sequential* or parallel treatment.^{24,34,37,39,65,66}

* Serial treatment is a term often used synonymously with sequential treatment

Integrated vs. Sequential vs. Parallel Treatment

Reviews commissioned in the U.S., in the mid-1980's by the National Institute of Mental Health (NIMH), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA), identified the problems encountered by people with concurrent disorders with treatment being provided across the two systems of care.^67,68 Recommendations called for better integration of mental health and substance abuse treatment. This was followed up with a demonstration program which developed and evaluated various interventions within the context of integrated models. While there are several different ways in which treatment integration can be operationalized the following definition will be used:

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 (adapted from Drake and Mueser.)⁶⁴

The more comprehensive integrated program models include common mental health interventions, such as medication management and support services, as well as assertive outreach, intensive case management, individual, group and family counseling and, on occasion, intensive day or residential components. Some of these features such as assertive outreach and intensive case management are critical features of Assertive Community Treatment (ACT) teams which can include substance abuse counselors. As the models for integrated treatment evolved, they incorporated interventions tailored to the person's stage of recovery,⁶¹ motivational interviewing and a range of other service activities (see Drake and Mueser⁶⁴ for an overview, and Mueser et al.,⁴⁴ for a detailed outline of specific interventions within their integrated treatment model).

In contrast to integrated treatment, sequential treatment was a term that referred to one treatment (either mental health or substance abuse) followed by the other treatment, but through referral to another agency, or specialized unit within the same treatment organization.⁶⁵ An example would be a person receiving counseling for panic attacks at a community mental health center and who is referred to a local substance abuse treatment service to deal with frequent binge drinking. The terms sequential or serial treatment were meant to imply that first the person would deal with one set of problems and then the other, but through two agencies or treatment units working largely independent of each other.

A parallel model of treatment referred to the simultaneous, concurrent treatment of both the psychiatric disorder(s) and substance use disorder(s) by two separate agencies, or two specialized units within the same treatment facility.⁶⁵ As with the definition of sequential treatment, the term parallel treatment was meant to imply that clinicians in the two agencies or treatment units were working largely independent of each other.

Hence, the primary distinction between sequential, parallel and integrated treatment has been the implication that the latter involves concurrent treatment in terms of concepts, personnel, program and facility.²⁴

The Need for New Systems Terminology

While the three terms reflected very distinct approaches when they were first proposed, their definitions have become somewhat dated and blurred with the advent of a more systems approach to treatment,⁶⁹ and the exploration of various strategies to improve the coordination of services spread along a continuum of care that spans treatment units or agencies in the community.^{31,32,33,45,70-72} Specific examples of system coordination strategies are discussed in more detail in Section 4.4.2. In short, there are many ways to better integrate an individual's treatment and support across units within the same facility or across community agencies. This increasing collaboration blurs the distinction between the old terms of integrated treatment and sequential or parallel treatment.

In this report, a distinction between "program integration" (as per the original integrated model), and "systems integration" to reflect innovations underway to improve care and support across treatment units or community agencies is proposed. The earlier definition of integrated treatment is used as the definition of program-level integration. However, even in the context of an integrated program (i.e. one treatment/support plan with the same clinician(s) and support worker(s) in the same program) specific interventions for substance use and mental health disorders may be delivered either concurrently or sequentially depending on the particular combination of disorders, and the urgency that may arise within the individual circumstance (e.g., life threatening issues that must be given priority). Concurrent or sequential interventions in an integrated program model will be delivered in the context of an agreed upon treatment and support plan, and a consistent and co-ordinated team approach tailored to the unique needs and capacities of the individual.

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 services 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, this treatment plan may involve addressing the substance use 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.

Integration at the program level has been the subject of considerable research.^35,44,64 Models for system integration, however, have been much less frequently evaluated. This situation is likely to change over the next several years as accountability demands increase to show that models to improve service coordination ultimately translate into improved consumer outcomes and cost-effectiveness. This variation in research evidence, notwithstanding, there is no compelling evidence at present to recommend program-level integration over system-level integration, or vice versa. Subsequent recommendations about the importance of integrated treatment are meant to encourage integration from both program-specific and systemic perspectives.

* This definition is adapted from the definition of systems integration employed in the ACCESS project for the homeless in the U.S. ⁷¹]

The Need to Monitor Integration Activities

Organizational and larger systemic changes often require culture shifts and time to evolve. For example, what may begin as a collaborative initiative to cross-train staff may evolve into supplementary program components (e.g., a mental health agency may begin offering an substance abuse support group). It may then evolve further into a more fully integrated service (e.g., all consumers entering a mental health/agency are screened for substance abuse, and if needed, their individualized treatment and support plan covers both the mental health and substance use disorder).

Since efforts toward system integration may evolve over time, including the drift away from initial intentions, the development and widespread application of monitoring measures is recommended to assess the degree and type of system integration that has been achieved within any one organization that spans both addictions and mental health, or within a larger network of programs in the community. Integration should not be permitted to devolve into treatment that places responsibility for integration solely on individual therapists who may, for example, be more comfortable dealing with mental health issues to the exclusion of the substance use problems or vise versa.

The Need for Psychosocial Supports

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.⁷³ 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 facilitating more long-term positive outcomes. However, it also advocates for supporting the person in a wide variety of areas, including housing, employment, recreation, and social networks. 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.⁷⁴ The goals of these psychosocial support services are helping persons with severe mental illness become reintegrated into the community, and improving their quality of life and that of their families.

The psychosocial support services are recommended as part of the overall package of care and support for people with severe mental illness (see for example, the schizophrenia practice guidelines).¹⁵ Therefore, we would like to emphasize 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,⁴⁴ it may not be immediately obvious given the widespread use of the term integrated treatment. Thus, we prefer the term integrated treatment and support as it is more consistent with this broader psychosocial rehabilitation perspective.