Guidelines for Treatment and Support of People with Concurrent Substance Use and Mental Disorders
Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 9
In the spring of 2001, Health Canada released a report on the topic of treatment and support of people with co-occurring substance use and mental disorders.1 The report was developed by a multidisciplinary team, led by the present author, and was the outcome of more than twelve months of data gathering, research synthesis and consensus building. It concluded with best practice recommendations for improved service delivery and better integration across the specialized sectors of addiction and mental health service delivery.
My purpose in this article is to give an overview of the project and its main recommendations, and also to discuss some of the issues dealt with by the study team in the course of the project. I also discuss issues that have arisen in reaction to the Best Practices report and talk about the application of the report in the community and its potential to make a meaningful difference for people with co-occurring mental and substance use disorders.
The project was initiated by Health Canada’s Federal/Provincial/Territorial Committee on Alcohol and Other Drug Issues as one of several initiatives undertaken within the Canada Drug Strategy. The focus on concurrent disorders was intended to build upon a series of other documents commissioned by this group concerning substance abuse treatment and rehabilitation (e.g., treatment guidelines, youth, women).
Scope of the Work
In terms of overall project scope, the work commissioned by Health Canada was to address the gulf that had emerged over time between the specialized sectors of substance abuse and mental health services. Although the project team recognized the important role of more generic health, social and correctional services in the identification, treatment and support of people with concurrent disorders, for purposes of the project, priority was placed on the specialized services. We also gave priority to treatment and support services in relation to prevention or health promotion in order to keep the project manageable within the budget that we had been allocated. This priority also reflected the state of the current literature in this area, although it has been satisfying to see a recent report released in the US that has given more attention to prevention issues.
Building the Case for Improved Services and Systems
With the benefit of hindsight, I can safely say that the easy part of our task was our review of the literature, showing the high rate of concurrent disorders – or co-morbidity – in both the general population and treatment populations, as well as the clear evidence of poorer outcomes and elevated risk of many other health and social consequences. Of particular importance is the research evidence showing poor treatment engagement and difficulties in establishing therapeutic alliances. I believe this reflects issues related to stigma and problems in current service delivery models as much, if not more, than features of the co-morbidity itself. We also benefited considerably from a rich literature that has emerged from the US and elsewhere about the poor coordination between mental health and addiction services, a situation also seen to contribute significantly to poor consumer outcomes. A small Canadian literature, combined with our focus groups with consumers and interviews with key informants across the country, confirmed these systemic problems in Canada. In general, the information we collected and synthesized clearly pointed to the need for more integrated services as part of the solution. Defining just what was meant by integration, however, was another matter.
The Definition of Concurrent Disorders
Following similar work on treatment improvement protocols completed in the US,3 and a standard approach seen in much of the literature, we adopted a diagnosisbased definition of concurrent disorders: namely any combination of a substance use disorder (abuse or dependence) and mental disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This generated considerable debate in the project team, especially among those more aligned with the addiction than the mental health field. We did reach consensus, however, on a DSM-based approach, in consideration of the need to build treatment and support recommendations upon a foundation of diagnosis (or diagnoses) arising from the assessment process. Our diagnostic approach was also validated during the consumer focus groups as we heard the personal stories of being bounced back and forth between the two systems without the benefit of a full psychiatric assessment that could, over time, untangle the interactive mix of addiction and psychiatric symptoms. However, it was during my first presentation to the Federal/Provincial/Territorial committee that I began to appreciate that our definition would be interpreted by some in the addiction field as a ‘re-medicalization’ of addictions in Canada.
During workshops and other presentations on the Best Practice report, I soon began to devote as much as 20% of the presentation time explaining not only what DSM-IV was, but how addiction services in Canada had drifted so far away from the medical/psychiatric community that it was time for a rapprochement of sorts. When I made it clear that the assessment and treatment skills of psychiatrists as well as clinical psychologists† were needed among the community team for concurrent disorders, the concerns were allayed somewhat. But the sensitivities around the role of psychiatry in the addictions field in Canada need to be noted and dealt with constructively by anyone working to take the Best Practice report to the next level of community application. For me, a more important issue is the limited availability of psychiatrists and clinical psychologists to support the assessment process and, in the case of psychiatry specifically, to also assist through medication management and other treatment approaches.
Our use of a diagnostic approach also supported what I consider to be one of the major contributions of the report: namely, the need to consider several distinct sub-populations among people with concurrent disorders. Human nature being what it is, there is a tendency in this field to talk as if people with concurrent disorders represent one homogeneous group of people, when in fact the assessment issues and treatment and support recommendations are completely different for several important sub-populations. We separated mood and anxiety disorders, severe and persistent mental illness (sometimes known simply as ‘severe mental illness’ or SMI), personality disorders and eating disorders, each of which also can be broken down much further.
In the wake of the de-institutionalization of psychiatric hospitals, people with SMI have emerged as the priority population for community mental health services and, with respect to concurrent disorders, have been the subject of the most intense and systematic research program.4 However, this high-need sub-population is rarely seen in addiction treatment services, compared to those with mood and anxiety disorders, personality disorders, and other problems related to anger, impulsivity and/or aggression. The fact that the people coming through each of the two systems are so different influences the choice of screening tools, referral linkages for follow-up assessment, and in-house requirements for clinical competencies or skills. Yet these differences get almost no consideration in the planning or policy development process.
The Best Practice Recommendation
Our subsequent recommendations were directed at two levels. The first was the system-level and, most importantly, included calls for top-down policy development necessary to support bottom-up community coordination activities such as service agreements, other local coordinating mechanisms and pilot projects. We also recommended improved training and educational curricula as well as local cross-training, where personnel from each system train one another. This is one of the lowest cost and potentially high impact approaches to improved coordination of services. We also decried the lack of evaluation at the system level that would produce better evidence about the link between various coordinating mechanisms and actual consumer outcomes.
At the service delivery level, we organized our recommendations in three areas: screening, assessment and treatment/support. As important as the treatment/ support recommendations are for front-line workers, in terms of their potential for immediate and lasting acting impact at a system level, the recommendations concerning the need for universal screening for concurrent disorders in both mental health and substance abuse services may well be the most significant. The research is very convincing that a large percentage of people in contact with mental health and substance abuse services have concurrent disorders that go undetected. Of course, if this isn’t detected in the first place, then the later steps in the process – assessment, treatment and support planning – will be negatively impacted.
I have discussed how our report segmented the concurrent disorder population into separate subgroups, which clearly require different treatment and support approaches. I should note, however, that the research evidence supporting the recommendations specific to each sub-group is clearly stronger in some areas than others (e.g., substance abuse and SMI, compared to substance abuse and personality disorders or eating disorders).
The report also made an important and much neglected distinction between the integration of services and the sequencing of interventions. For example, the evidence is strong that services for people with SMI and substance use disorders are best delivered in an integrated service delivery model and simultaneously. This stands in contrast with our recommendation for depression and alcohol abuse where a sequenced approach makes more sense for a significant majority of consumers, given the high probability that the depressive symptoms will improve following a period of abstention or reduction in alcohol intake. While the recommended treatment in this case would be sequenced, the services would still be delivered in integrated fashion, meaning that the consumer him or herself wouldn’t have to negotiate two separate and uncoordinated ‘streams’ of care. Also highlighted is the need for ongoing case monitoring and assessment to assess effectiveness of initial treatment plans.
Finally, we made an important and also much neglected distinction between program versus systemlevel integration. We noted that the repeated call in the literature for integrated services was based primarily on two things: (1) an almost exclusive focus on people with SMI and substance use disorders (i.e., the most severe and highest need sub-population) and (2) the inherent problems with so-called ‘parallel’ or ‘sequential’ services delivered by two or more programs that do not communicate with each other in the assessment, treatment/support and follow-up process.
In the emergent era of increased inter-agency collaboration, partnerships and service agreements, we felt it was important to also advocate for new innovative models of inter-organizational service delivery. Such approaches are needed as an alternative to a more restrictive vision of integration. At the local level, this all too often translated into having a capability for dealing with concurrent disorders only in the form of individual, highly specialized programs. Such exclusive, program-level integration also made no sense in the context of all the different sub-groups of concurrent disorders, where many people are quite adequately dealt with through programs that are still ‘sequential’ or ‘parallel,’ to use the old language, but which take a coordinated approach to delivering care to the individual. Our emphasis on systemic integration also points clearly to the need for upgrading the general capability for addressing concurrent disorders across all provider organizations and clinicians, as opposed to building only highly specialized services.
Chances for a Making a Difference
Health policy and health services research are abuzz these days with terms such as ‘knowledge transfer’ and ‘evidence-based practice.’ Clearly our Best Practice report tapped into a groundswell of felt need and one would like to think that the enthusiastic response should auger well for the uptake of many of our recommendations. Unfortunately, effecting change at the levels of clinician and organizational behaviour, as well as making broad systemic change, will require more than information and enthusiasm. Meaningful change requires more than just additional funding – although I should point out the chronic underfunding of community mental health and addictions services across Canada, especially in comparison to the institutional sector. I recognize it is a challenge to talk about addressing the needs of particular sub-populations when budgets have been flatlined for several years, at least in Ontario, and programs are struggling to maintain base-level services in a quality manner.
auger well for the uptake of many of our recommendations. Unfortunately, effecting change at the levels of clinician and organizational behaviour, as well as making broad systemic change, will require more than information and enthusiasm. Meaningful change requires more than just additional funding – although I should point out the chronic underfunding of community mental health and addictions services across Canada, especially in comparison to the institutional sector. I recognize it is a challenge to talk about addressing the needs of particular sub-populations when budgets have been flatlined for several years, at least in Ontario, and programs are struggling to maintain base-level services in a quality manner.
The BC health authorities have, however, been mandated to address the integration of these sectors at the regional service delivery level. In Ontario, very little movement has been made toward provincial policy development. We do have a provincial program of concurrent disorder activities underway though the Centre for Addiction and Mental Health – including for example, training activities, a stigma project, a family intervention project, research on screening tools, descriptions of program models – as well as service coordination activities in a number of communities.
These are all positive signs, which no doubt mirror to some extent the situation in most provinces. What is lacking, however, in each province and nationally, is a planned and well-funded research and development program with clear targets for system change and strategies grounded in current evidence regarding change processes and knowledge transfer. We have no national forum or focal point for discussion and sharing of ideas and experiences; no mechanism to prevent duplication of effort; no process to identify and support regional and provincial champions of the change proc ess; no toolkits to transform the information from the Best Practice report and other sources into more userfriendly advice; and perhaps, most importantly, no baseline data or national research plan that will give us performance indicators to measure ongoing improvement in service delivery and consumer outcomes.
These are all elements of effective knowledge exchange strategies, and they are being implemented in some jurisdictions through more strategic planning and dedicated resources.5 Although implementation of the Best Practice report is essentially a provincial responsibility, the dissemination process could benefit from more focus and leadership at a national level. This could be incorporated into ongoing activity in the context of the Canada Drug Strategy or an overall national mental health strategy, such as may be recommended by the anticipated Kirby Report and advanced by groups such as the Canadian Alliance for Mental Health and Mental Illness. It may also be the time for innovative bridges to be built across the Canada Drug Strategy and an emergent national mental health strategy. What better way than to lead by example.
About the Author
Brian is a Senior Scientist and Associate Director of the Health Systems Research and Consulting Unit at the Centre for Addiction and Mental Health, Toronto, Ontario. He was the Project Leader of Health Canada's Best Practices: Concurrent Mental Health and Substance Use Disorders initative
Centre for Addiciton and Mental Health. (2012) Best practices: Concurrent mental health and substance use disorders. Ottawa: Health Canada. See www.cds.sca.com
Substance Abuse and Mental Health Services. Administration. (2002) Report to Congress on the prevention and treatment of co-occuring substanceabuse disorders and mental disorders.Rockville, MD: Substance Abuse and Mental Health Services Adminstration. See www.samhsa.gov/reports/congress2002/index.html
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Museser, K Noordsy, DL, Drake, RE & Fox, L (2003). Integrated treatment for dual disorders. A guide to effective practiceNew York: Guildford Press.
Panzano, PC, Roth, D Massatti, R, Crane-Ross, D & Carstens, C (2002). The innovation diffusion and adoption research project (IDARP): Moving from the diffusion of research results to promoting the adoption of evidence-based innovations in the Ohio Mental Health System. New Research in Mental Health, 15, 149-156.