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The Co-occurring Treatment Crisis

The Co-Occuring Treatment Crisis

In any given year, 5.6 million adults in the United States have co-occurring mental health and substance use disorders. On average, the cost of treating those with co-occurring disorders is about twice the cost of treating individuals with either a substance use or mental health disorder. Those with co-occurring disorders more frequently relapse, tend to be medication noncompliant, and are more likely to be

• hospitalized,
• violent,
• incarcerated,
• homeless, and
• infected with HIV, hepatitis, and other diseases (Drake et al., 2001; see Resources | SAMHSA).

An estimated 50% of homeless adults with serious mental illnesses have a co-occurring substance use disorder. According to the United States Department of Justice, jail detainees have a 72 percent rate of co-occurring disorders. A 2008 study summarized in a May 2011 TEDS report found that 18.3% of substance abuse treatment admissions aged 18 to 64 were labor force dropouts. Approximately 29.8% of those dropouts had a co-occurring disorder.

The Hazards of Nonintegrated Treatment

Until recently, the mental health and addiction treatment communities have operated independently. As a result, they developed very different treatment styles, so clients with co-occurring disorders have received inconsistent care.

In sequential systems, when one disorder is treated first, the following can happen:

• The untreated disorder can worsen the disorder being addressed, making it impossible to stabilize one disorder without attending to the other.
• The treatment facilities may not agree on which disorder should be treated first, jeopardizing outcomes
• e.g., a bipolar client is unable to receive medications from a mental health clinic while using alcohol or other drugs.
• It may be unclear when one disorder has been successfully treated so that the treatment of the other disorder can start.

With parallel treatment, when the client is treated by separate treatment teams or even at separate facilities, the following can happen:

• If the two branches fail to communicate well, the burden of integration is placed on the client, who is often ill-prepared to handle the responsibility.
• The treatment philosophies are often different enough to make combined treatment incompatible.
• Providers may lack a common language and treatment methodology to provide effective parallel treatment.
• There are funding and eligibility barriers to assessing both treatments, making it difficult for clients to get the needed treatment.
• A client may slip through the cracks and receive no services, due to neither provider assuming final responsibility for the client.

In general, then, nonintegrated treatment is associated with the following negative consequences:

• People tend to drop out of treatment.
• Their mental health symptoms are likely to worsen.
• Over time they might actually increase their use of alcohol or other drugs to self-medicate.
• They have more legal, social, family, and medical problems.
• Their chances for recovery are less than average.

The Cost of Nonintegrated Treatment

Costs rise even higher when those with co-occurring disorders repeatedly cycle through health care and criminal justice systems as many have been shown to do. Without the establishment of more integrated treatment programs, the cycle will continue.

Of those with co-occurring disorders, about

• 50% get no treatment at all;
• 33% get only mental health or addiction care;
• 10% get concurrent treatment for both disorders, but in separate programs;
• 2% get evidence-based integrated treatment.

Studies have shown that those with co-occurring disorders who received care in systems in which mental health and substance abuse treatment were separate were often excluded from services by one program and told to return when the other problem was under control. Those who received services in nonintegrated systems of care also had difficulty making sense of disparate messages about treatment and recovery. Consequently, the evidence demonstrated that consumers with co-occurring disorders in nonintegrated systems of care have poor outcomes (Drake et al., 2001; see Resources | SAMHSA).

The Integrated Treatment Solution

The Integrated Treatment Solution

The evidence-based practice of integrated treatment is the most effective service strategy available for those with co-occurring disorders, demonstrating consistent, positive outcomes among clients.

Integrated treatment is a research-proven approach that utilizes one competent treatment team to recognize and address a client’s co-occurring mental health and substance use disorders at the same time, in the same setting.

In taking an integrated approach to treatment, neither the mental health nor the substance use disorder is identified as being “primary” or “underlying” to the other. Clinicians see to it that interventions work hand-in-hand; the clients then receive consistent treatment, with no division between mental health or substance abuse assistance. The approach and recommendations are seamless, and the need to consult with separate teams and programs is eliminated.

The Effectiveness of Integrated Treatment

In contrast with nonintegrated treatment, integrated treatment is associated with the following positive outcomes such as

• reduced substance use,
• improvement in psychiatric symptoms and functioning,
• decreased hospitalization,
• increased housing stability,
• fewer arrests, and
• improved quality of life (Drake et al., 2001; see Resources | SAMHSA).

Benchmarks for Evidence-based Integrated Treatment*

Your behavioral health system may already provide both mental health and substance abuse treatment programs. While these services likely share characteristics of the evidence-based model, important distinctions exist.

Eight studies support the effectiveness of integrated treatment for co-occurring disorders. While the type and array of interventions in these programs vary, they include the critical components outlined in the Integrated Treatment Fidelity Scale.

The following benchmarks help organizations assess whether their integrated treatment program provides services in a manner that adheres to the evidence-based model.

• Multidisciplinary Team
  

  Case managers, psychiatrist nurses, residential staff, and vocational specialists work collaboratively on a mental health treatment team.

• Integrated Substance Abuse Specialist
  

  A substance abuse specialist works collaboratively with the treatment team, modeling co-occurring disorders treatment skills and training other staff in co-occurring disorders treatment.

• Stage-Wise Interventions
  

  Treatment is consistent with each client’s stage of recovery (engagement, persuasion, active treatment, relapse prevention).

• Access for Clients with Co-occurring Disorders to Comprehensive Dual Disorders Services
  

  Residential services, supported employment, family psychoeducation, illness management, and ACT or ICM are provided.

• Time-Unlimited Services
  

  Substance abuse counseling, supported employment, illness management, residential services, family psychoeducation, and ACT or ICM are provided.

• Outreach
  

  The program demonstrates consistently well-thought-out strategies and uses outreach to the community whenever appropriate

• Motivational Interventions
  

  Clinicians who treat co-occurring disorders express empathy, avoid argumentation, instill self-efficacy and hope, roll with resistance, and distinguish between goals and continued use.

• Substance Abuse Counseling
  

  Clients who are in the active-treatment stage or relapse-prevention stage receive substance abuse counseling that includes relapse-prevention strategies, refusal skills, problem-solving skills, coping skills, and social skills.

• Group Dual Disorders Treatment
  

  Dual disorders clients are offered group treatment specifically designed to address both mental health and substance use problems.

• Family Dual Disorders Treatment
  

  Clinicians provide loved ones with education about dual disorders, coping skills training, support, and the opportunity to collaborate with the treatment team.

• Participation in Alcohol and Drug Peer Recovery Support Groups
  

  Clients who are in the active-treatment stage or relapse-prevention stage attend self-help programs in the community.

• Pharmacological Treatment
  

  Prescribers work closely with the treatment team and client, prescribe psychiatric medications despite active substance use, focus on increasing adherence, and help clients avoid addictive substances.

• Interventions to Promote Health
  

  Clinicians teach clients how to avoid infectious diseases; help them avoid high-risk situations; and encourage them to pursue work, medical care, diet, and exercise.

• Secondary Interventions for Substance Abuse Treatment Nonresponders
  

  The program has a protocol for identifying substance abuse treatment nonresponders and offers individualized secondary interventions, such as trauma treatment, intensive monitoring, and long-term residential care.

*Adapted from the Integrated Dual Disorders Treatment (IDDT) Fidelity Scale developed by the Dartmouth PRC.

A Blueprint for Integrated Treatment

Similar to recovery from either a substance use or mental health disorder, recovery from co-occurring disorders is a lifelong process that benefits from a spectrum of factors. External factors such as supportive funding streams and public policies provide the foundation for an environment that is conducive for the delivery of integrated services. Similarly, true integrated treatment, as described in the above benchmarks, is most effective when delivered within a community that is rich with resources that someone with co-occurring disorders will need throughout his or her recovery, such as peer recovery groups, community-based professional support, employment, and safe housing.

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The Cost-Effectiveness of Integrated Treatment

In light of the aforementioned outcomes for the individual with co-occurring disorders, it is clear that the costs to the individual and his or her community are far decreased with an effective integrated treatment approach.

A study conducted by Ohio SAMI on behavioral health care claims data in Ohio found that Integrated Dual Disorders Treatment (IDDT) helped save $1.4 million in service costs for a group of 160 people with severe mental illness and co-occurring substance use disorders. Identified as an evidence-based practice by the Substance Abuse and Mental Health Services Administration (SAMHSA), IDDT calls for mental health and substance abuse treatment to be delivered at the same place, at the same time, and with the same treatment team.