Availability of Integrated Care for Co-occurring Substance Abuse and Psychiatric Conditions

The co-occurrence of psychiatric conditions and substance abuse presents significant challenges for behavioral healthcare providers. The need for integrated care has received substantial recent attention from clinical, research, and funding entities. However, the availability of integrated care has been low, carrying potential adverse implications for quality of care and treatment outcomes. This article describes the prevalence and key correlates of the availability of integrated care for co-occurring conditions within public and private-sector addiction treatment programs. Several organizational attributes, caseload characteristics, and service provision patterns were associated with the availability of integrated care.Lori J. Ducharme, Hannah K. Knudsen, and Paul M. Roman are affiliated with the Center for Research on Behavioral Health and Human Services Delivery, Institute for Behavioral Research, University of Georgia.     

Treatment for Dual Diagnosis Patients in the Psychiatric and Substance Abuse Systems

The purpose of this study was to describe and compare the extent to which psychiatric and substance abuse programs treating dual diagnosis patients in the residential and outpatient modalities offered the components recommended for this client group. Surveys were completed by managers of 753 programs in the Department of Veterans Affairs that had a treatment regimen oriented to dual diagnosis patients. Programs within both the psychiatric and substance abuse systems had some of the key services of integrated treatment (e.g., assessment and diagnosis, crisis intervention, counseling targeted at psychiatric and at substance use problems, medications, patient education, HIV screening and counseling, family counseling and education). However, compared to psychiatric programs, substance abuse programs were more likely to offer some of these services and other critical components (e.g., a cognitive-behavioral treatment orientation, assignment of a single case manager to each patient). Outpatient psychiatric programs were particularly lacking on key management practices (e.g., use of clinical practice guidelines, performance monitoring of providers) and services (e.g., detoxification, 12-step meetings) of integrated treatment. Generally, differences between psychiatric and substance abuse programs appeared to involve difficulties in developing treatment that is fully oriented toward the co-occurring diagnosis. To improve the provision of high-quality dual-focused care, we recommend planners' use of cross-system teams and applications of recently produced tools designed to increase programs' ability to deliver integrated care to dually disordered individuals.     

Screening for Psychiatric Disorders among Adults Presenting for Substance Use Disorder Treatment: Current Practices in the United States

This paper provides a brief overview of the status of screening, assessment, and management of psychiatric problems in substance use disorder (SUD) treatment settings in the USA. The literature shows that current best clinical practices guidelines support integrated treatment of co-occurring disorders (CODs) in SUD treatment programs, but in practice such care occurs at a low–moderate frequency, and is implemented inconsistently and with uneven quality across treatment settings. Several barriers to the consistent implementation of empirically supported COD assessment and treatment are discussed, with the conclusion that progress with such implementation depends heavily on administrative and health care system support and investment.     

Treating Homeless Clients with Severe Mental Illness and Substance Use Disorders: Costs and Outcomes

This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.The authors thank the study participants for their co-operation in this study; we hope that their lives have improved as a result of their participation. We also appreciate the co-operation of the many agencies that provided treatment to the study participants, particularly Community Alternatives, Places for People, and Peter and Paul Community Services. The following individuals were critical to the execution of the project: Ruth Smith, Mary Maguire, Bill Tourville, Joris Miller, Gretchen Gerteis, Gail Saulnier, Kecia Smith, Dorothy Gano, Jean Mayo and Melinda Bowen. We are also grateful to the many people and agencies who provided service utilization and cost information, particularly Mr. Ed Meyers of the Missouri Department of Mental Health, Mr. Richard Koon and Melanie Neal of the Missouri Department of Social Services, Ron Konkol of the Social Security Administration, Francie Broderick and Kelly Wilson of Places for People, Steve Campbell of Peter and Paul Community Services, Bob Harvey and Marsha Wood of Independence Center, Debra Wilderman of St. Louis University Hospital, Karen Jessop of St. Alexius Hospital, Julia Rogliano of South Pointe Hospital, Nelda James of Barnes Hospital, and Joyce Ellison of the St. Louis Veterans Administration Hospital. Financial support was provided by the National Institute of Mental Health, (MH 57154) and the University of Missouri-St. Louis. However, the views expressed in this paper are the sole responsibility of the authors.Dr. Gary A. Morse is with Community Alternatives, St. Louis, MO, USA.Drs. Robert J. Calsyn, Thomas W. Helminiak and Mr. Matthew R. Lemming are with the University of Missouri-St. Louis, St. Louis, MO, USA.Dr. Robert D. Yonker is now with the University of Toledo, Toledo, OH, USA.Dr. W. Dean Klinkenberg, Mr. Gyanesh Lama and Ms. Suzanne McCudden are with the Missouri Institute of Mental Health, St. Louis, MO, USA.Dr. Nancy Wolff is with Rutgers University, New Brunswick, NJ, USA.Dr. Robert E. Drake is at the Dartmouth Medical School, Hanover, NH, USA.     

Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorders

There is a significant need for advanced understanding of treatment of co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Approximately half of individuals seeking SUD treatment meet criteria for current PTSD, and individuals with co-occurring PTSD-SUD tend to have poorer treatment outcomes compared with those without such comorbidity. However, there is not sufficient empirical evidence to determine a best course of treatment for these individuals. This paper provides a review of the literature relevant to the treatment of co-occurring PTSD-SUD. To date, treatment studies have focused primarily on non-exposure-based psychosocial treatments, exposure-based psychosocial treatments, and medication trials. The most promising outcome data thus far are for psychosocial treatments that incorporate an exposure therapy component; however, further research is needed, particularly as related to how best to implement these approaches in real-world treatment settings.     

Addictions and Trauma Recovery: An Integrated Approach

The co-occurence of addiction with trauma-based mental health problems forms a toxic feedback loop, creating assessment and treatment challenges for consumers and their healthcare providers. Traditional separation of addiction and mental health treatment has contributed to a high level of recidivism among clients challenged by trauma and addiction problems. A new treatment model rooted in an understanding of trauma re-enactment, is described. ATRIUM integrates cognitive behavioral and relational treatment through an approach which stresses mind, body, and spiritual health.     

Caregiving for Relatives with Psychiatric Disorders vs. Co-Occurring Psychiatric and Substance Use Disorders

Despite the high comorbidity of psychiatric and substance use disorders, extremely little research has examined the experience of caregiving for relatives with co-occurring psychiatric and substance use disorders (COD). The primary objective of the present article is to identify characteristics pertaining to care recipients, family caregivers, and the experience of providing caregiving associated with care recipients having COD vs. only having psychiatric disorders (PD). A U.S. community recruited sample of 1394 family caregivers of persons with COD or PD was employed. Chi-square and Mann-Whitney-Wilcoxon tests were conducted. Compared to caregivers of persons with only PD, caregivers of persons with COD provided slightly less caregiving but experienced significantly greater negative effects from providing care. Caregivers of persons with COD were also more likely to fear care recipients would engage in multiple problematic behaviors. Most significant differences found in providing care to recipients with COD vs. only PD persisted when examining care recipients with severe psychiatric disorders or more moderate psychiatric disorders. Additional findings and treatment implications are described.     

Multidisciplinary Treatment for Adults with Autism Spectrum Disorder and Co-Occurring Mental Health Disorders: Adapting Clinical Research Tools to Everyday Clinical Practice

ABSTRACT

In California, individuals with autism and co-occurring mental disorders, and their families, face two serious barriers when attempting to access the mental health services they need. The first is that the State Mental Health Specialty Service guidelines specifically exclude autism as a qualifying primary diagnosis for eligibility for mental health treatment and funding. The second is the lack of understanding and awareness regarding the challenges faced by individuals with classic autism and co-occurring mental disorders and their families. These two barriers, combined with the absence of a clear protocol for referral and assessment, have made access to services for clients and their families difficult. The Adult Autism Spectrum Disorder and Co-Occurring Mental Health Disorders project was an opportunity to study potential assessment tools and referral guidelines. We evaluated the use in a clinical setting of the Schedule for the Assessment of Psychiatric Problems Associated with Autism—a research instrument designed specifically for the psychiatric evaluation of patients with autism—to assist in diagnosing co-occurring mental health disorders. The experience gained in this study helped identify effective treatment options as well. After the assessment, clients were offered choices among several possible treatments fitting their specific needs. Our experience indicates that while adapting a research tool to everyday clinical service may encourage a more rigorous standardized approach to clinical assessment and evaluation, it may be difficult to employ such a tool in a clinical setting because of service needs and managed care constraints of serving a large and diverse population.     

Older Adult Patients with Both Psychiatric and Substance Abuse Disorders: Prevalence and Health Service Use

The prevalence and service use among older adults with concurrent psychiatric and substance abuse disorders (the dually diagnosed) was examined in a cross-sectional survey of a representative national sample of Department of Veterans Affairs mental health program patients (N = 91,752). Rates of dual diagnosis declined significantly (P = 0.001) as the age of the respondents increased (26.7% of patients < 65 years; 6.9% of patients 65 years). Dually diagnosed older adult patients had longer inpatient stays for substance abuse and more outpatient substance abuse visits than did non-dually diagnosed elderly patients, and more outpatient general psychiatric visits than all the contrast groups. Dual diagnosis appears less common among older compared to younger patients, although their heavy use of certain (particularly, outpatient psychiatric) services suggests that should more dually diagnosed patients survive to old age their consumption of some forms of mental health care is likely to be high.     

Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders

The long-term courses of people with schizophrenia and of those with substance use disorder have been studied separately and extensively. The long-term course of clients with co-occurring schizophrenic and substance use disorders has, however, not been examined. This article reports 10-year outcomes for 130 clients with co-occurring schizophrenic and substance use disorders in the New Hampshire Dual Diagnosis Study. In addition, we report on 6 "recovery outcomes," identified by dual diagnosis clients, as examples of positive coping behaviors. Longitudinal data were modeled using generalized estimating equation (GEE) methods. Participants improved steadily over 10 years in the outcome domains of symptoms, substance abuse, institutionalization, functional status, and quality of life. Further, at the 10-year follow-up, substantial proportions were above cutoffs selected by dual diagnosis clients as indicators of recovery: 62.7% were controlling symptoms of schizophrenia; 62.5% were actively attaining remissions from substance abuse; 56.8% were in independent living situations; 41.4% were competitively employed; 48.9% had regular social contacts with non-substance abusers; and 58.3% expressed overall life satisfaction. These 6 outcomes were only weakly interrelated over time, suggesting that recovery, as defined by clients, is a multidimensional concept. Overall, the 10-year findings on recovery outcomes provide a hopeful long-term perspective for dual diagnosis clients.     

Risk of Reincarceration Among Prisoners with Co-occurring Severe Mental Illness and Substance Use Disorders

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.     

Substance Use and Five-Year Survival in Washington State Mental Hospitals

This report combines five-year survival and cause of death in individuals discharged from Washington State mental hospitals with (1) mental illness only, (2) co-occurring mental illness and substance use disorder, or (3) substance use disorder only. Five-year survival was similar in the three groups, although after adjusting for age, individuals with co-occurring disorders or substance use disorder were almost 50% more likely to die than those with mental illness only. Persons with these conditions need treatment to prevent premature death and medical conditions directly related to substance use disorder.     

Risk of Future Offense Among Probationers with Co-occurring Substance Use and Mental Health Disorders

The criminal justice system is the primary service delivery system for many adults with drug and alcohol dependence, mental health, and other health service needs. The purpose of this study was to examine the relationship between risk of future offense, mental health status and co-occurring disorders in a large substance abuse diversion probationer population. A purposive sample of 2,077 probationers completed an assessment to screen for mental health disorders, substance use disorders, risk of future crime and violence, and several demographic characteristics. Probationers who screened positive for co-occurring substance use and mental health disorders were significantly more likely to be at higher risk of future crime and violence compared to probationers who screened positive for only substance use, only a mental health disorder, or no substance use or mental health disorder. Implications for substance use and mental health service delivery are discussed, and recommendations are made for further research.