Concurrent Disorders Treatment

On this page:

• Integrated treatment
• Approaches to treatment
• Evidence-based care

Whereas, in the past, substance use and mental health services were often part of separate treatment systems, it is now increasingly recognized that care, for many clients, needs to involve both systems and be delivered in ways that are co-ordinated and collaborative. Treatment for concurrent disorders can be provided at different levels of co-ordination (the choice of level is often determined by the level of severity of the substance use and mental health problems, and the availability of services in a community).

• consultation: informal linkages between substance use, mental health and other social service agencies
• collaboration: formal links between agencies; can be appropriate for clients who have one moderate and one severe problem (e.g., staff from a mental health and a substance use agency working together to design and implement a treatment plan)
• integration: integrated programs providing substance use and mental health treatment within a single treatment setting. Comprehensive integrated program models have been developed in response to the needs of clients with severe mental illness.

Integrated treatment

Integrated treatment is founded on the assumption that there is a close relationship between substance use and mental health problems and that one problem shouldn't be treated in isolation from the other. The concept was developed to respond to the difficulties clients had when navigating between the substance use and mental health systems. Drake and Mueser (2000) suggest that integrating treatment services shifts the responsibility for navigating and negotiating the complexities of diverse treatment approaches from clients/consumers to the people and agencies that deliver the services.

Broadly defined, integrated treatment is “any mechanism by which treatment interventions for [concurrent disorders] are combined within the context of a primary treatment relationship or service setting” (SAMHSA, 2003, p. 59). One clinician or treatment team takes overall responsibility for blending treatment and support interventions into one coherent package (Drake et al., 2004).

Much of the literature on integrated treatment has concentrated on clients who have substance use and severe mental health problems, particularly psychotic disorders. The needs of this population led to an emphasis on treating substance use and mental health problems simultaneously and within the same treatment program. The definition of integrated treatment has since been widened to also include approaches that involve co-ordination among staff from two or more agencies. This expanded definition also allows for staging of treatment interventions within one co-ordinated treatment plan. Because the approach is co-ordinated and consistent, the treatment should appear seamless to the client (Health Canada, 2002).

Program/service-level integration

In integrated programs or services, substance use and mental health treatments are delivered by one team of clinicians and support workers in the same treatment setting (Health Canada, 2002). Most integrated programs that have demonstrated good outcomes include:

• staged interventions
• assertive outreach
• motivational interventions
• counselling
• social support interventions (Drake et al., 2001).

System-level integration

If all integrated care required that clients be served in a single program, current service systems would have to be rebuilt from the ground up. As mental health and addiction providers and funders realize the need to work more effectively with clients with complex problems, they are turning to improvements that do not require the creation of a new treatment system. Existing systems can offer improved treatment for the full continuum of concurrent disorders if they establish links among treatment programs, some of which have the capacity to deliver both substance use and mental health treatment, and others that co-ordinate services among two or more agencies, allowing each agency to customize treatment to suit the population it serves (Health Canada, 2002).

Components of an integrated system

With the recognition of the high rates of co-occurrence of substance use and mental health problems comes an expectation that all substance use and mental health programs will develop at least a basic level of skill at identifying, assessing and working with clients with concurrent disorders.

Kenneth Minkoff (2001) describes four levels of agency capability, based on program categories from the American Society of Addiction Medicine. Using his model, but adapting his terminology to the language of concurrent disorders we are using here, the levels are as follows:

1. Concurrent Disorders Capable—Addictions Program: welcomes people with co-occurring disorders whose conditions are sufficiently stable, so that neither symptoms nor disability significantly interferes with standard treatment. Makes provision for concurrent disorders in program mission, screening, assessment, treatment planning, psychopharmacology policies, program content, discharge planning, and staff competency and training.

2. Concurrent Disorders Capable—Mental Health Program: welcomes people with active substance use disorders for mental health treatment. Makes provisions for concurrent disorders as above. Incorporates integrated continuity of case management and/or stage-specific programming, depending on type of program.

3. Concurrent Disorders Enhanced—Addictions Program: program enhanced to accommodate people with subacute mental health symptomatology or moderate disability. Enhanced mental health staffing and programming, increased levels of staffing, staff competency and supervision. Increased co-ordination with continuing mental health or integrated treatment settings.

4. Concurrent Disorders Enhanced—Mental Health Program: mental health program with increased substance-related staffing skill or programmatic design. For example: 2 day treatment unit, providing addiction programming in a psychiatrically managed setting; intensive case management teams, providing premotivational engagement and stage-specific treatment for the most impaired and disengaged individuals with active substance disorders; comprehensive housing or day programs, providing multiple types of stage-specific treatment interventions and substance-related expectations.

Approaches to treatment

Treatment for concurrent disorders needs to include:

• screening both for substance use and for mental health problems
• comprehensive assessment
• psychosocial and pharmacological interventions (SAMHSA, 2003)
• a plan for continuing care and support.

However, because the population is heterogeneous, no one set of interventions will be effective for all clients with concurrent disorders (Kavanagh et al., 2003).

Evidence-based care

Definitions

Research using randomized controlled clinical trials is the gold standard for validating the effectiveness of a treatment intervention in a given population. The next best evidentiary base is research using quasi-experimental designs (comparison groups assigned by randomization), followed by open clinical trials (no independent comparison group). While the evidence base for concurrent disorders interventions is growing, very little in this domain meets that gold standard yet (SAMHSA, 2003).

The (U.S.) Institute of Medicine (2000) has suggested that, where results from randomized clinical trials are not available, it is appropriate to use the following criteria to evaluate treatment approaches:

• best research evidence: clinically relevant research, often from the basic health and medical sciences, but especially from patient-centred clinical research, into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative and preventive regimens

• clinical expertise: the ability to use clinical skills and past experience to identify and treat each client’s unique state and diagnosis, to assess the individual risks and benefits of potential interventions, and to do so within the context of the patient’s personal values and expectations

• patient values: the preferences, concerns and expectations each patient brings to a clinical encounter, which must be integrated into clinical decisions if they are to serve the patient.

Evidence for treatment interventions

When we consider the evidence that supports approaches to helping people with concurrent disorders, we need to look at subpopulations. Best practices guidelines published by Health Canada (2002) concluded that there was sufficient evidence to support dividing subpopulations into groups who have co-occurring substance use and:

• mood and anxiety disorders
• severe and persistent mental health disorders
• personality disorders
• eating disorders
• other mental health disorders.

For each group, the report reviewed the evidence for:

• what sequencing of substance use and mental health interventions was most effective
• what treatment approaches were most effective.

Despite the high prevalence of concurrent mood, anxiety, impulsivity and substance use problems, and depression and substance use problems (20 to 30 per cent of the general population), there is still very little evidence on appropriate treatment interventions for this group (Kavanagh, 2003). The stronger body of concurrent disorders research with clients with severe mental health problems (which occur in two to three per cent of the general population) needs to be extended to the other domains, where better evaluated treatments could help inform concurrent disorders treatment practices.

Within the concurrent substance use and severe mental illness subgroup, better evidence exists for overall approaches (integrated treatment, stage-wise treatment, motivational techniques) than for any specific treatment intervention (Drake et al., 2004). We need to know more about what components of integrated treatment are the most helpful to clients. The capacity to provide support, beyond episodes of care from which clients are discharged, appears to be an important feature in producing effective outcomes, avoiding relapses and helping clients live more successfully in the community.

Customizing the helping response to the client’s stage of treatment and recovery, combined with a pragmatic harm-reduction orientation, appears to enhance engagement and lead to better working relationships between client and counsellor, and to better outcomes (Roth, 1999).

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