National Dialog on Co-occuring Mental Health and Substance Abuse Disorders

June 16-17, 1998
Washington, DC

Sponsored by:

National Association of State Mental Health Program Directors (NASMHPD)
66 Canal Center Plaza, Suite 302, Alexandria, VA 22314
(703) 739-9333, FAX (703) 548-9517

National Association of State Alcohol and Drug Abuse Directors (NASADAD)
808 – 17th Street, N.W., Suite 410, Washington, D.C. 20006
(202) 293-0090, FAX (202) 293-1250

Supported by:

Center for Substance Abuse Treatment (CSAT)
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services (CMHS)
Substance Abuse and Mental Health Services Administration

TABLE OF CONTENTS

ACKNOWLEDGMENTS

EXECUTIVE SUMMARY

INTRODUCTION

SECTION I: Background

SECTION II: The Conceptual Framework

SECTION III: Desirable System Characteristics

SECTION IV: Recommendations

CONCLUSION

APPENDIX A Agenda and Meeting Participants

APPENDIX B Resource Materials

APPENDIX C World Wide Web Sites

ACKNOWLEDGMENTS

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD) view the National Dialogue on Co-occurring Disorders as precedent-setting in both substance and process. We wish to acknowledge the willingness of all the participating State Mental Health Commissioners and State Alcohol and Other Drug Directors to suspend traditional positions in the creation of the innovative co-occurring framework introduced in this document. Participating State AOD Directors included Michael Couty (MO), Lewis Gallant, Ph.D., (VA), Elizabeth Howell, M.D. (GA), Thomas Kirk, Ph.D. (CT), Sherry Knapp, Ph.D. (RI), and Mayra Rodriquez-Howard (MA). Mental Health Commissioners included Sharon Autio (MN), Stephen Mayberg, Ph.D. (CA), James Stone, M.S.W. (NY), Marylou Sudders (MA), Roy Wilson, M.D. (MO) and Tom Fritz (DE).

Special thanks are due each of the distinguished subject area experts who so ably informed the discussions: Jerry Carroll, Ph.D., Robin Clarke, Ph.D., Bert Pepper, M.D., and Marc Schuckit, M.D. Both Associations wish to express their appreciation for the vision, guidance and consideration so willingly provided by the Government Project Officers: Carol Coley, M.S., of the Center for Substance Abuse Treatment (CSAT) and Michael English, JD, from the Center for Mental Health Services (CMHS). We would be remiss if we failed to also acknowledge the contributions of Eileen Elias (CMHS) and George Kanuck (CSAT).

NASMHPD and NASADAD wish to thank Commissioner James Stone and his staff at the N.Y. Office of Mental Health for their contributions to this document, including the graphics. We acknowledge the contributions of Paul Berreira, M.D., of the Massachusetts Department of Mental Health.

Susan Milstrey-Wells prepared the first draft of this document and earned our gratitude for her high professional standards.

Other NASADAD and NASMHPD members also made significant contributions, as did many knowledgeable officials from SAMHSA, CMHS and CSAT. While they cannot all be identified here their work on behalf of this project is truly appreciated.

Finally, we wish to recognize all Association staff who have worked in support of this effort. Special thanks are given to Bruce Emery, M.S.W. and Bob Anderson who served so capably as Project Directors for NASMHPD and NASADAD, respectively.

Robert W. Glover, Ph.D.                               John S. Gustafson
NASMHPD Executive Director                     NASADAD Executive Director

Washington, D.C.

March, 1999

EXECUTIVE SUMMARY

The human and economic toll of co-occurring mental health and substance abuse disorders in this country demands immediate attention. Though the problems associated with co-occurring disorders have long been acknowledged and discussed, there has been little consensus about how to accomplish needed system change.

The National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders, held June 16-17, 1998, in Washington, DC, offered participants an unprecedented opportunity to address this critical issue. Supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and two of its centers – the Center for Mental Health Services and the Center for Substance Abuse Treatment – the meeting was co-sponsored by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD). Invited participants included State mental health commissioners and alcohol and drug abuse directors, expert panelists, and Federal officials.

State alcohol and drug abuse directors and State mental health commissioners, whose dialogue forms the basis of this White Paper, exemplified a broad spectrum of treatment, administrative, and funding arrangements. Their extensive, collective experience framed the group’s discussions and shaped an agenda for change.

Estimates suggest that up to 10 million people in this country have a combination of at least one co-occurring mental health and substance-related disorder in any given year (SAMHSA NAC, 1997). But numbers only begin to tell the story. Individuals with co-occurring disorders tend to have multiple health and social problems and to require costly care. Many are at increased risk for incarceration and for homelessness.

Historically, there have been a number of barriers to the provision of appropriate treatment for dually-diagnosed individuals. Most notably, there is no single locus of responsibility for people with co-occurring disorders. The mental health and substance abuse treatment systems operate independently of one another, as separate cultures, each with its own treatment philosophies, administrative structures, and funding mechanisms. This lack of coordination means that neither consumers nor providers move easily among service settings.

To reach any type of consensus on treatment and services for people with co-occurring disorders, the substance abuse and mental health communities need to develop a shared perspective and to speak the same language. Toward this end, participants in the National Dialogue developed a conceptual framework that represents a new paradigm for considering both the needs of individuals with co-occurring disorders and the system requirements designed to address these needs.

Among its unique characteristics, the framework conceptualizes co-occurring disorders in terms of symptom multiplicity and severity rather than specific diagnoses, thereby encompassing the full range of people who have co-occurring mental health and substance abuse disorders. In addition, it specifies the level of service coordination – defined as consultation, collaboration, or integration – needed to improve consumer outcomes. This makes it flexible enough to address the needs of all individuals with co-occurring disorders and to be adopted or adapted for use in any service setting.

Finally, the framework points to the need for special attention to two groups: 1) individuals, especially children and adolescents, who are at risk for developing more serious disease; and 2) people with severe substance abuse and mental health disorders who may be found in jails, in forensic hospitals, in emergency rooms, or living on the streets. Individuals in these two groups are among those most poorly served by the current uncoordinated system of care.

A comprehensive service system designed to address the needs of people with co-occurring disorders must have support at the highest levels, meeting participants agreed. Further, it must be consumer-centered, culturally competent and feature a “no-wrong door” approach, i.e., services must be available and accessible no matter where and how an individual enters the system. The use of common data and assessment tools, staff who are trained in each other”s disciplines, and flexible funding mechanisms are also critical components for success. Regardless of the specific organizational structure of the system, it must comprehensively address consumer needs in a coordinated manner.

The conceptual framework points to three specific levels of service coordination among the mental health, substance abuse, and primary health care systems required to address the needs of people with co-occurring disorders. These levels of coordination correspond to the level of severity of the disorder. The greater the severity, the more intense the level of coordination required to guarantee effective service delivery. The continuum of intensity begins with informal consultation, which ensures that both mental illness and substance abuse problems are addressed; moves to more formal collaboration, which ensures that both substance abuse and mental illness problems are included in the treatment regimen; and ends with services integration, which merges mental health and substance abuse efforts into a single treatment setting and treatment regimen. Each of the three types of coordination efforts requires a joint vision and ongoing commitment. In addition, shared treatment planning and interdisciplinary service teams help make all three types of coordination efforts more effective.

Each of the key players who participated in the meeting – the Federal agencies that supported the event, the national association sponsors, the State commissioners and directors and substance abuse and mental health experts – has an important role to play in system change. Meeting participants encouraged SAMHSA, through its Centers, to collect and disseminate best practice models; recommended that the States develop specific mechanisms to encourage, allow, and fund the collaborative efforts required to address the needs of this population; and urged NASMHPD and NASADAD to make co-occurring disorders a priority for each group separately and for both organizations together. Participants agreed to use the framework to continue the dialogue on co-occurring disorders.

Participants in the National Dialogue pledged to continue the work they began together and to involve all relevant stakeholders, including mental health and substance abuse providers and consumers and their families, in ongoing efforts to improve health outcomes for people with co-occurring disorders. Continued cooperation at the Federal, State, and local level will ensure that this effort proceeds with both deliberate speed and appropriate care.

INTRODUCTION

The co-occurrence of mental health and substance abuse disorders has a significant impact on individuals’ lives, on their families, on health care delivery and costs, and on society as a whole. Though the problems associated with co-occurring disorders have long been acknowledged and discussed, there has been little consensus about how to accomplish needed system change.

The National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders, held June 16-17, 1998, in Washington, DC, offered participants an unprecedented opportunity to address this critical issue. Supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and two of its centers – the Center for Substance Abuse Treatment and the Center for Mental Health Services – the meeting was co-sponsored and facilitated by the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD). Invited participants included State mental health commissioners and alcohol and drug abuse directors, expert panelists, and Federal officials.

State mental health commissioners and State alcohol and drug abuse directors, whose dialogue forms the basis of this White Paper, exemplified a broad spectrum of treatment, administrative, and funding arrangements. These individuals represented State mental health and alcohol and drug abuse systems that are separate; those in which mental health and substance abuse agencies are combined; States where both the mental health and alcohol and drug abuse director were present at the meeting; large and small systems; and urban, rural, and mixed geographic areas. Their extensive, collective experience framed the group’s discussions and shaped an agenda for change.

Participants gathered with a set of ambitious goals. Specifically, they set out to:

In the process of defining the population and identifying specific groups within it, meeting participants created a conceptual framework that represents a new paradigm for addressing co-occurring disorders. The framework permits a comprehensive discussion of symptom severity, locus of care, and level of service coordination required to address the needs of all individuals who have co-occurring mental health and substance abuse disorders. It also allows for future discussion of funding opportunities.

Further, the framework is flexible enough to be applicable to any service setting, even those in which service integration is not feasible. Finally, it points to the need for special attention to two groups: 1) people with severe substance abuse and mental health disorders who may be found in jails, in forensic hospitals, in emergency rooms, or living on the streets and who clearly need fully integrated services in order to achieve beneficial outcomes; 2) individuals, especially children and adolescents, who have less severe problems at present but who are at risk for developing more serious disease.

The meeting itself represented the type of collective effort that participants agreed is vital to addressing the needs of people with co-occurring disorders. Each of the participating groups had clearly defined roles that contributed to the outcome. Specifically, the Federal agencies that supported the meeting provided the catalyst for bringing the group together. The national associations co-sponsored and facilitated the process, and the State commissioners and directors determined the meeting’s content and outcome. Expert panelists helped lay the groundwork for a shared understanding of the key issues that must be addressed.

Participants’ contributions paralleled the recommendation that each group has a specific role to play in accomplishing system change. SAMHSA can provide needed support, and NASMHPD and NASADAD can keep this issue at the forefront of their agendas. Researchers and experts can continue to advance the field’s knowledge of co-occurring disorders. The bulk of the work of creating a more effective service system for people with co-occurring mental health and substance abuse disorders, however, must take place at the State and local levels through the efforts of policy makers, providers, consumers, and advocates. The conceptual framework provides an important tool to develop solutions tailored to a community’s needs.

This report represents a summary of the group’s discussions and the products it developed. Section I describes in brief the characteristics of the population and some historic barriers to providing care for people with co-occurring disorders. Section II outlines and describes the conceptual framework, which is based on a model originally developed by the State of New York.

Desirable characteristics of a comprehensive system of care for people with co-occurring disorders are outlined in Section III, with specific attention to the three forms of service coordination the group defined – consultation, collaboration, and integration. Finally, Section IV presents recommendations for future strategies designed to translate the theoretical underpinnings of the conceptual framework into practice.

Appendices include a record of participants and expert panelists, resources and a list of relevant World Wide Web sites. Individuals who would like more information about the problem of co-occurring disorders are encouraged to visit these sites, and to direct their questions and concerns to their State commissioners and directors and to NASMHPD and NASADAD representatives.