co-occurring mental and substance abuse disorders: a guide for mental health planning + advisory councils US Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health Services www.samhsa.gov This guide will help state co-occurring mental and substance abuse mental health planning disorders and advisory council members and others Prevalence and Characteristics One in every five adults, or about 44 million Americans, assess the programs experiences some type of mental disorder every year. Moreover, five percent of Americans have a severe and per- and services in their state sistent mental illness such as schizophrenia and schizoaffec- tive disorders, major depression, and bipolar disorder.1 plans for people who According to the U.S. Surgeon General, the United States spent more than $99 billion for mental, addictive, and dementia disorders in 1996. Indirect costs of all mental ill- have co-occurring mental ness in 1990, the most recent year for which estimates are available, totaled $79 billion dollars. These costs include and substance abuse those associated with lost productivity and premature death. disorders. Many individuals with serious mental illnesses have a co- occurring substance abuse disorder. Estimates suggest that up to 7 million adults in this country have a combination of at least one co-occurring mental health and substance-relat- ed disorder in any given year.2In comparison to individuals with a primary mental or substance abuse disorder, individu- als with co-occurring disorders tend to be more sympto- matic, have multiple health and social problems, and require more costly care, including inpatient hospitalization. Many are at increased risk of homelessness and incarceration. Of an estimated 600,000 people who are homeless on any given day, approximately 25 to 30 percent have a mental ill- ness.3As many as one half of all people who are homeless and have a serious mental illness also have a substance abuse disorder.4The number of persons with co-occurring mental health and substance abuse disorders, who are also involved with the criminal justice system, is reaching epidemic propor- tions. About 10 million adults each year enter U.S. jails;5about 2003 700,000 of these individuals have co-occurring disorders.6 More then two million youth under the age of 18 are arrested each year, half of whom will have contact with the juvenile 3 justice system. A high percentage of these youth experience both serious mental health and substance abuse problems.7 The presence of co-occurring mental and substance abuse disorders is complex as the illnesses interact with and exacer- bate one another. Emerging research suggests that mental disorders often precede substance abuse. It is also the case that alcohol and drug abuse and withdrawal can cause or worsen symptoms of mental illnesses. Substance use also can mask symptoms of mental illness, particularly when alcohol or drugs of abuse are used to “medicate” the mental illness. One disorder may interfere with an individual’s ability to benefit from and participate in treatment for an other disorder. Dysfunctional and maladaptive behaviors can be attributed to either disorder. Individuals with untreated mental disorders are at increased risk for substance abuse. Similarly, individuals who abuse alcohol and other drugs are at increased risk for experiencing mental disorders. While there is a good deal of variability from person to per- son and no single set of co-occurring disorders, experts now agree that co-occurring disorders should be seen as the expectation among persons with serious mental illness, not the exception. Therefore, our treatment systems must be designed with their needs in mind. Unfortunately, for people with co-occurring disorders, the decision to seek professional help can be frustrating and confusing whether they enter the mental health or the sub- stance abuse treatment systems. The mental health system traditionally has tended to exclude persons who also abuse substances, maintaining that the primary work of providers is with mental illness and not with substance abuse. Substance abuse programs often have excluded from treatment persons with mental illness who were taking prescribed medications by requiring individuals entering treatment to demonstrate their motivation by being “clean” of all drugs – including prescribed medications. Many substance abuse treatment programs have relied heav- ily on confronting the individual’s denial of a problem at all. 5 To the contrary, mental health treatment often focuses on partnership that resulted in the development of a new shoring the individual’s fragile defenses, taking a supportive conceptual framework that presents co-occurring disorders rather than confrontational approach. Historical differences in terms of multiple symptoms and severity instead of in culture, philosophy, structure, and funding have con- diagnosis. The framework provides a visual way of thinking tributed to a lack of coordination that has made it difficult about both the systems of care and the level of service coor- for either consumers or providers to move easily across serv- dination needed to improve consumer outcomes, especially ice settings. the integrated care necessary for individuals with the most severe mental illnesses and substance use. This conceptual These and other differences have contributed to inadequate framework combines observations about the current service and costly care and the failure of either system to address delivery systems with a vision for the future delivery of the comprehensive needs of consumers. Many of these indi- integrated services. viduals have long histories of engaging in self-destructive behaviors to cope with the pain of their illnesses. These behaviors often worsen symptoms and cause the individual Service coordination by Severity to lose hope of recovery. People with co-occurring disorders may then become stuck in a cycle of pain, alienation, and self-destructiveness that isolates them from their personal support systems and from treatment systems. Providers themselves may become frustrated, not understanding how to help individuals move away from self-destructive patterns of behavior. Inadequate and costly care has been the result. Individuals and providers both remain stuck in a cycle of hopelessness, with the person with co-occurring disorders feeling like a misfit – “unwelcome, unwanted, and blamed for the complexity of their difficulties.”8 Fortunately, in recent years a growing consensus has emerged asserting the need to do more for this population. Both mental health and substance abuse service providers and systems have a responsibility to understand the disease processes and help clients recover. Research is available that points the way. Integrated Treatment Beginning in 1998 with the support of the Substance Abuse and Mental Health Services Administration (SAMHSA), the U.S. Department of Health and Human Services, the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD) entered into a 6 7 Typically, if they are treated at all, individuals with less severe door” philosophy; that is, no matter how the individual mental disorders and less severe substance abuse, enter the enters care, the services needed to respond effectively to an service system through a primary care setting (Quadrant I). individual with both severe mental illness and severe These individuals may present to a primary care doctor, a substance abuse are available and accessible. Integrated school-based health clinic or other primary care setting. For services are often offered through a single-service agency persons with mild mental disorders or substance abuse prob- whose staff have been cross-trained and are competent to lems, it may be appropriate to manage their psychiatric med- respond to the unique challenges of co-occurring disorders. ications and other treatments in less intensive or specialized Unfortunately, integrated services are not currently available settings, such as primary care. When necessary, individuals in most communities. Consequently, many individuals who may be referred to specialized service agencies or providers. would benefit from integrated treatment find themselves in Those individuals with increasingly severe mental disorders hospital emergency rooms, jails and prisons, and other non- accompanied by a lower level of substance abuse are more health-oriented settings, that may not meet their needs. likely to be seen in a community mental health setting, There is growing support for the work being conducted by which provides treatment for the primary mental disorder the State Mental Health and Substance Abuse Directors. and also may address the substance abuse problems In 1999, SAMHSA issued a policy statement that enthusiasti- (Quadrant II). Individuals with a high degree of substance cally supported the conceptual framework for its ability to abuse and lower level of mental disorder typically are seen capture all levels of functional impairment related to mental primarily in substance abuse service settings (Quadrant III). illness and substance abuse and indicates a need to provide While the mental disorders of these individuals may be such services on a broader, more systematic basis. addressed, the agency’s primary expertise remains substance abuse. Referrals to other specialized service settings are com- mon in both Quadrants II and III. These referrals place the Cultural Competency burden of connecting the separate treatment systems squarely on the individual and family. A key responsibility of behavioral health care systems is to deliver effective services in an environment that is both wel- Both the mental health and substance abuse fields generally coming and responsive to individual needs, irrespective of agree that the most effective treatment for persons with ethnicity, national origin, language, race, religion, age, dis- substance abuse and severe mental illnesses – those found ability, gender, sexual orientation, or socioeconomic stand- in Quadrants II and IV – is integrated treatment, in which ing. Because the Nation’s population is shifting rapidly, this services are offered through a single, unified, comprehensive challenge is becoming more complicated. service system.9Integrated treatment matches the intensity of the disorders with a commensurate intensity of treatment For example, today, one in three Americans is non-white. By interventions. With increasing evidence that any substance 2050, projections place the population of non-white and/or abuse by persons with serious mental illness is potentially Latino individuals at 47 percent.10According to Mental destabilizing, some treatment professionals and researchers, Health: Culture, Race and Ethnicity, A Supplement to Mental therefore, are calling for integrated treatment to be available Health a Report of the Surgeon General(DHHS, 2001), to persons in Quadrant III as well. minorities are less likely than whites to receive needed men- tal health services and more likely to receive poor quality An integrated, community-based treatment setting is con- care. Minorities are over-represented among the Nation’s sumer-centered and provides services through a “no wrong most vulnerable populations (people who are homeless, 8 9 incarcerated, or institutionalized), with higher rates of mental consumers, and providers to redesign the State’s system for disorders and more barriers to care.11 delivering services to persons with co-occurring disorders. Regional planning groups are now examining mechanisms to These and other findings suggest it is more important than implement a “no wrong door” approach within a managed ever that persons with co-occuring mental and substance care framework. abuse disorders be offered services that are culturally-sensi- tive and tailored to their unique needs. Arizona. Arizona has utilized a consensus-building process to bring key stakeholders together to develop an action plan that outlines the goals and objectives of an ideal system of Promising Practices care for persons with co-occurring disorders across all quad- Great progress is being made by states and communities to rants. An integrated treatment consensus panel is working develop and implement effective services for persons with to identify gaps in service and make recommendations to co-occurring disorders. In some states, state mental health bridge them. agencies and state substance abuse agencies have begun the Connecticut. Several years ago, the State’s new Department process of long-term systems change to ensure more effec- of Mental Health and Addictions Services formed a task tive co-occurring disorder services. Other states have been force to design a service system that was more centered on collaborating, developing, implementing, and evaluating co- the needs of consumers. Significant resources have been occurring services for many years and have valuable lessons committed to cross-train and credential individuals who can to share. Examples of state programs are: demonstrate competence in a set of core skills necessary to Texas. The State is in its third round of support for pilot proj- serve people with co-occurring disorders. ects to serve persons with co-occurring disorders at all levels of New York. The State, building successfully upon the long- severity, with primary funding from the Substance Abuse standing working relationship between the mental health Prevention and Treatment (SAPT) Block Grant and State men- and substance abuse leadership, signed a Memorandum of tal health general revenue funds. Staff use an integrated serv- Understanding that commits resources and details plans to ice model to deliver services. A total of 14 pilots currently are fund pilot projects to serve persons with co-occurring disor- funded, using a “no wrong door” approach and fully cross- ders. Co-occurring disorders coordinators address service trained staff. delivery at the community level. Massachusetts. A Community Action Grant from SAMHSA’s New Hampshire. Some of the most notable work on co- Center for Mental Health Services was used to develop occurring disorders has been produced by the New a consensus model for service delivery to persons with Hampshire-Dartmouth Psychiatric Research Center to the co-occurring mental and addictive disorders. A statewide benefit of the State’s behavioral healthcare system. Local leadership council developed a set of principles for establish- mental health and substance abuse providers have formed ing a continuous, integrated system of care. Six regional partnerships to serve persons with co-occurring disorders groups have assumed responsibility for implementing a involved with the criminal justice system. Program evaluation pilot program in each of their communities based upon suggests there have been fewer arrests, emergency room vis- these principles. its, and hospital admissions among individuals enrolled in the Missouri. For several years, key leaders in the mental health program. and substance abuse fields have worked with legislators, Georgia. The State funds 13 regional units that plan services 10 11 for individuals with co-occurring disorders at the regional and community level. Financial incentives encourage regions and communities to save money by reducing use of State hospitals and to reinvest those funds in innovative programs, including co-occurring service programs. Virginia. Virginia has focused its efforts and resources on both a statewide training needs assessment and cross-train- ing experts to help ensure that mental health and substance abuse provider communities are kept up-to-date on the lat- est developments in providing services to persons with co- occurring disorders. Funding Issues A large gap exists between the services needed by persons with co-occurring disorders and the funds available to pay for those services across the country. Some advocates main- tain that funding, rather than client need, has dictated serv- ices. Different funds and funding streams are used to sup- port mental health and alcohol and drug abuse services in the States, including State general revenues, Medicaid, local taxes, the Community Mental Health Services (CMHS) Block Grant), and the Substance Abuse Prevention and Treatment (SAPT) Block Grant. Mental health planning and advisory council members should be aware that in the past there has been some con- cern and confusion about the use of the CMHS Block Grant and the SAPT Block Grant. As evidenced in the Promising Practicessection of this document, many states have found creative ways to fund services for persons with co-occurring disorders. A recent policy statement by the Substance Abuse and Mental Health Services Administration addressed this ques- tion of blended funding.12According to the statement, funds from the SAPT Block Grant and the CMHS Block Grant may be combined by States to support integrated treatment serv- ices for individuals with co-occurring disorders. The 20 per- cent set-aside for primary prevention services (part of the SAPT Block Grant) also may be used for prevention activities 12 for those at risk of developing co-occurring substance abuse It may be unrealistic to expect that many new resources and mental disorders. According to the same statement, will become available to serve people with co-occurring funds from each block grant must be allocated in a manner disorders. States and communities are encouraged to consistent with the purposes of the particular block grant. consider funding models that combine different streams of existing funds, and increase capacity in existing service Since states have established different accounting methods delivery systems. to track block grant funds, state mental health planning council members are advised to check with their state men- The Joint NASMHPD and NASADAD Task Force on Co- tal health and substance abuse authorities on their own Occurring Disorders recommends that, in light of funding state policies and practices. In addition, in some 24 States, constraints, state and community co-occurring service the substance abuse authority is a part of the mental health providers and advocates can support the best use of authority, offering a unique opportunity to develop strong available resources by encouraging healthcare service program and financial collaborations to serve persons with purchasers to: co-occurring mental and substance abuse disorders. •Purchase Effective Services. Good information is avail- able to help states and communities develop highly effective, integrated services for persons with co-occur- Role of Planning Councils ring disorders. Those models can be adopted or adapted State mental health planning and advisory councils can play to suit the needs of individual states. Resources that link a pivotal role in helping to plan, implement, monitor, and to relevant research on this topic are listed in the back advocate for effective services for persons with co-occurring of this guide. mental and substance abuse disorders. Successful services •Purchase Performance. Clear expectations should be set begin by building collaborations at all levels to provide for program performance, based on available research integrated responses to the serious problems faced by this and on community needs. A program’s effectiveness population. should be judged by the level of change it helps to bring in the lives of consumers with co-occurring sub- Specifically, state mental health planning council stance abuse and mental disorders and their families. members can - •Evaluate and Improve. Measurement of performance •Help ensure that the mental health and substance abuse outcomes is critical. Programs and the services they pro- provider communities are aware of the latest research vide should be evaluated continually to ensure they are available that documents effective, integrated systems achieving desired results. Rapid feedback to all key of care. Hold them accountable for delivering the best, stakeholders – including state mental health councils – state-of-the-science services helps ensure that expectations are met or revised, based •Become educated about service themselves about serv- on actual performance. ice programs nationwide that successfully serve persons with co-occurring disorders; study lessons from those with experience; and use that information to work with key providers, funders and advocates from across the state to help ensure that high quality care is available to persons with co-occurring disorders. 14 15 endnotes references 1 U.S. Department of Health and Human Services (1999). Mental Health: A Report of the Surgeon General. Washington, DC. 2 U.S. Department of Health and Human Services (1999). Mental Health: A Report of the Surgeon General. Washington, DC. The following documents form the basis of this brochure. 3 Center for Mental Health Services and Center for Substance Abuse Additional literature sources are cited to build a greater Treatment (2000). Insights and Inroads: Project Highlights of the understanding of treatment needs of individuals with CMHS and CSAT Collaborative Demonstration Program for co-occurring mental and substance abuse disorders and the Homeless Individuals. Rockville, MD: SAMHSA. role of state mental health planning councils in helping to 4 Lezak, A.D., and Edgar, E. (1996). Preventing Homelessness meet that treatment need. Among People With Serious Mental Illness: A Guide for States. Rockville, MD: CMHS, SAMHSA, and U.S. Department of Health U.S. Department of Health and Human Services (1999). and Human Services. Mental health: A report of the Surgeon General. 5 United States Department of Justice Statistics (1997). Correctional Washington, DC: Author. Populations in the United States. NCJ-163916. 6Bureau of Justice Statistics (1998). Prison and Jail Inmates at U.S. Department of Health and Human Services (2001). Midyear, 1997.Office of Justice Programs. Mental Health: Culture, Race, and Ethnicity-A Supplement 7Cocozza, J. (Ed.) (1992). Responding to the Mental Health Needs of to Mental Health: A Report of the Surgeon General. Youth in the Juvenile Justice System.Seattle, WA: The National Washington, DC: Author. Coalition for the Mentally Ill in the Criminal Justice System. Center for Mental Health Services (1998). Report of the 8 Center for Mental Health Services (1998). Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Center for Mental Health Services managed care initiative: Care, Practice Guidelines, Workforce Competencies and Training Clinical standards and workforce competencies project. Curricula. Rockville, MD: CMHS. CMHS Managed Care Initiative: Co-Occurring Mental and 9 Drake, R.E., Mercer-McFadden, C., Mueser, K.T., McHugo, G.J., Substance Disorders (Dual Diagnosis) Panel. Rockville, MD: and Bond, G.R. (1998). Review of Integrated Mental Health and SAMHSA, U.S. Department of Health and Human Substance Abuse Treatment for Patients with Co-Occurring Services, 1998. [On-line]. Available: www.samhsa.gov Disorders. Schizophrenia Bulletin, 24(4): 589-608. 10U.S. Bureau of the Census (1996). Resident Population of the Center for Substance Abuse Treatment (1994). Assessment United States: Middle Series Projection, 1996-2000 by Sex, Race and treatment of patients with co-existing mental illness and Origin, with Median Age. Washington, DC: Population and alcohol and other drug abuse. Treatment Division, U.S. Bureau of the Census. Improvement Protocol (TIP) Series (Volume 9). Rockville, 11National Technical Assistance Center for State Mental Health MD: SAMHSA, U.S. Department of Health and Human Planning (1999). Cultural Diversity Series: Meeting the Mental Services, 1994. [On-line]. Available: www.samhsa.gov Health Needs of Gay, Lesbian, Bisexual and Transgender Persons. Alexandria, VA: Author. Drake, R., Essock, S., Shaner, A., Carey, K., Minkoff, K., Kola, 12Substance Abuse and Mental Health Services Administration L., Lynde, D., Osher, F., Clark, R., Rickards, L. (2001). (1999). Position statement on use of Substance Abuse Prevention Implementing Dual Diagnosis Services for Clients With and Treatment Block Grant and Community Mental Health Services Block Grant Funds to treat people with co-occurring disorders. Severe Mental Illness. Psychiatric Services, 52 (4), 469-476. Rockville, MD: SAMHSA, U. S. Department of Health and Human Services. 16 17 Drake, R.E., Mueser, K.T., Clark, R.E. and Wallach, M.A resources (1996). The course, treatment and outcome of substance disorder in persons with severe mental illness. American Journal of Orthopsychiatry, 66 (1):42-51. US Department of Health and Human Services Drake, R.E., et al. (1998). Reading in dual diagnosis. Substance Abuse and Mental Health Columbia, MD: International Association of Psychosocial Services Administration Rehabilitation Services. Center for Mental Health Services Center for Substance Abuse Treatment Kessler, R.C. (1994). The national comorbidity survey of Center for Substance Abuse Prevention the United States. International Review of Psychiatry, 5600 Fishers Lane 6:365-76 Rocckville, MD 20857 Web site: www.samhsa.gov Minkoff, K. (1989). An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and SAMHSA's National Clearinghouse for Alcohol Community Psychiatry.40: 1031-1036. and Drug Information National Association of State Mental Health Program Web site: www.health.org Directors Research Institute, Inc. (1999). Funding sources and expenditures of state mental health agencies: FY SAMHSA's National Mental Health Information Center 1997.Alexandria, VA: Author. Web site: www.mentalhealth.org National Association of State Alcohol and Drug Abuse National Association of State Mental Directors and National Association of State Mental Health Health Program Directors Directors (2000). Financing and marketing the new con- 66 Canal Center Plaza ceptual framework for co-occurring mental health and Suite 302 substance abuse disorders: A blueprint for systems Alexandria, VA 22314 change. Final Report of the Second National Dialogue of Phone: (703) 739-9333 the Joint NASMHPD-NASADAD Task Force on Co- Fax: (703) 548-9517 Occurring Disorders.Alexandria, VA: Authors. Web site: www.nasmhpd.org National Association of State Mental Health Directors and National Association of State Alcohol and Drug Abuse National Association of State Alcohol and Directors (1999). National dialogue on co-occurring men- Drug Abuse Directors tal health and substance abuse disorders: June 16-17, 808 17th St., NW 1998. Final Report of the First National Dialogue of the Suite 410 Joint NASMHPD-NASADAD Task Force on Co-Occurring Washington, DC 20006 Disorders. Alexandria, VA: Authors. Phone: (202) 293-0090 Fax: (202) 293-1250 Regier, D., et al. (1990). Co-morbidity of mental disorders E-Mail: [email protected] with alcohol and other drugs: Results from the epidemio- Web site: www.nasadad.org logic catchment area (ECA) study. Journal of the American Medical Association, 264 (19), 2511-2518. 18 19