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We are pleased to welcome Dr. Mark McGovern, an Associate Professor of Psychiatry and of Community and Family Medicine at Dartmouth Medical School in Lebanon, New Hampshire. He is based at the Dartmouth Psychiatric Research Center, which specializes in the design, development, testing and dissemination of evidence-based treatments for persons with co-occurring disorders. Dr. McGovern is a practicing clinician, conducts treatment and services research with co-occurring substance use and psychiatric disorders, and is the Editor-In-Chief of the Journal of Substance Abuse Treatment.
Question: It seems as though we have been talking about co-occurring disorders for many years, yet keep we hearing that better service integration is still needed. What accounts for this ongoing problem?
Answer: Much as we reassure our individual patients that change can be difficult, may take time, and is influenced by stage of readiness, so it goes with systems change. Dating back to the 1980s, groundbreaking work by Bert Pepper, Carol Caton, Robert Drake, Richard Rosenthal, Richard Ries, Kenneth Minkoff and many others raised awareness of the high rates of comorbidity among persons with either substance use or mental health disorders. Research, most notably by Drake, Mueser and colleagues, demonstrated evidence for the benefits of integrated treatment approaches (i.e. treating both disorders at the same time, by the same team of providers), particularly for persons with severe and persistent mental illness. Through the second millennium, with the leadership of SAMHSA and using the co-occurring state incentive grant mechanism (COSIG), state systems embarked on improving their policies, practices and workforce to address the needs of persons with co-occurring disorders. Particularly through the efforts of Kenneth Minkoff, Christine Cline and the Co-Occurring Center for Excellence led by Stanley Sacks, the field began to move from a pre-contemplative or contemplative stage of readiness, to an action orientation. However, recent SAMHSA data revealed that less than 10% of persons with co-occurring disorders receive concurrent care, and even fewer receive integrated services (SAMHSA, 2008). Clearly, although evidence-based treatments have been developed, and awareness has been raised, perseverance is needed to guarantee the availability of integrated services to those who need them most.
Question: Is there any evidence that either the system of care or the treatment programs providing services have improved in their capability to address co-occurring disorders?
Answer: In research initially funded by the Robert Wood Johnson Foundation Substance Abuse Policy Research Program, and presently supported by SAMHSA, a collaboration of States has formed a learning community to improve co-occurring capacity. Most of the State system members of this learning community have implemented the benchmark measures of program co-occurring capability, the Dual Diagnosis Capability in Addiction Treatment (DDCAT) and/or Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) indexes. These measures have served to guide these members by providing objective and systematic data about system and program capacity. This information sheds light on service variation, and also, can be used to target and measure change initiatives. In fact, using data gathered across nine States, addiction treatment programs increased the level of co-occurring services from “addiction only” to “dual diagnosis capable” threefold, and mental health programs raised services fourfold to dual diagnosis capable during a nine to twelve month period. These findings demonstrate that when systems and programs use objective criteria, and identify specific and practical change targets, improvement in capability is not only possible but clearly measurable.
Question: Can you say more about the kinds of changes programs have made using the DDCAT and DDCMHT measures as benchmark guideposts?
Answer: Many providers feel overwhelmed at the prospect, or more accurately, the potential cost of increasing their capability to address co-occurring disorders. The initial belief is that to do so a fundamental change in workforce is needed, in particular increased physician time. Since most provider budgets are focused on organizational survival with zero or less financial growth, the possibility of increased costs is daunting. Meanwhile, treatment providers want to do the right thing and get their patients the best treatment possible to foster the recovery process. It turns out that most of the benchmarks on the DDCAT and DDCMHT can be leveraged favorably at no to little economic investment. Examples include developing a memorandum of understanding between service providers to assess, treat and refer common patients with co-occurring disorders who straddle their care, or installing a public-domain (i.e. free) standardized screening measure to reliably detect substance use or psychiatric problems. Many more options exist to improve services that are not particularly cost intensive.
There are two other points worth making in response to this question.
First, although these systems and programs have made positive changes, many of these changes have occurred in the assessment process. By this I mean that programs have increased access to their services by persons with co-occurring disorders via shifts in policy or admission criteria, and have refined their screening, assessment and differential diagnostic protocols. Therefore, more persons with co-occurring disorders are being identified up front, and such individuals have a complex set of problems and needs. Providers are just beginning to implement psychosocial treatments to respond. Of course, FDA-approved medications are available for both psychiatric and addictive disorders, but these medicines are far from “silver bullets” or cures. Psychosocial treatments are at least as effective as medications for most disorders, in some cases more effective (e.g. co-occurring substance use and PTSD), but the combination of both being perhaps being the most efficacious. The next stage of clinical improvement for many programs is the systematic implementation of psychosocial treatment (individual and group) for their patients with co-occurring disorders.
The second important point is the value of staff training. Typically, when organizational leaders consider improving capacity to address co-occurring disorders, the reflexive response is to seek training, either via day long or even week long in-service or off-site workshops. Implementation science research has consistently shown that training, or at least training alone, does not result in practice change. Our own research within the multi-state learning community has in fact replicated this finding: Training is not associated with increased program capability to address co-occurring disorders. So, leaders are advised to consider training as an initial step in information or knowledge exposure. Practice change is a more difficult and complex step.
Question: You mentioned the importance of psychosocial treatments, in individual and group formats, in addressing the needs of persons with co-occurring disorders. Why is it difficult for clinicians to address co-occurring disorders?
Answer: This is indeed an interesting question, and a conversation we seem to have frequently. Mental health clinicians typically have little or no educational or practical experience with addictive disorders. Across the major mental health disciplines including psychiatry, clinical psychology, clinical social work, and mental health counseling, substance use disorders and their treatment remain a small part if not an “elective” in their professional development. As such, there is some sense that addressing substance use involves some highly specialized knowledge or skill-set that is well beyond their clinical capability. Of course, in reality, all of these disciplines have a standard set of skills in assessment, treatment planning and interventions, most of which are similar if not identical to what addiction “specialists” might use. What is different is the focus.
The same is true for traditional addiction professionals, particularly addiction counselors. Counselors conduct detailed clinical interviews, intervene with individuals and groups, and rely on motivational interviewing or motivational enhancement, and cognitive behavioral (e.g. relapse prevention, anger management, functional analysis) strategies. These skills are readily broadened to address mental health concerns.
Of course good clinical supervision will be necessary as these professionals expand the focus of their interventions to address problems or disorders they have previously referred, neglected or believed would be addressed by leveraging the disorder they did know about. Clinical supervision, unlike training alone, is one implementation strategy that does appear associated with practice change.
In summary, what seems to be difficult in making the transition is the lack of felt expertise, anxiety about doing something new, the availability of good clinical supervision from a “master” clinician, and to some extent not utilizing available manual-guided materials that make delivering these psychosocial therapies relatively straightforward.
Question: With the advent of health insurance and health care reform upon us, what can be expected in service and systems change for persons with co-occurring disorders?
Answer: Although it these changes seem likely, until the regulations attached to these reforms are released, no one knows exactly how things will change. However, it seems probable that pressure to avoid duplication in service delivery, as well as performance based contracting, will result in potentially better integration of mental health and addiction treatment services with routine health care.
This could provide an excellent opportunity to identify problems among persons at earlier stages, so that treatments could be preventive or early intervention in nature. The benefits of a “medical home” may in fact foster integration of medical, mental health and addiction services. This might contribute to treating whole persons, rather than using fragmented approaches based upon artificial splits in the system of care. The promises of better treatment coordination, “no wrong door” and improved access to specialty medical care (mental health and addiction) seem more possible.
However, efforts to introduce mental health and addiction assessment and treatment in routine medical settings have suffered several major problems.
The first problem is the a la carte manner in which behavioral health experts have attempted to integrate services. This series of efforts has included tobacco and smoking, alcohol, depression, and drug use. A variety of models, including the Screening, Brief Intervention and Referral to Treatment (SBIRT), have focused on one or the other of these behavioral health problems, and has not recognized the co-occurring or multi-morbid nature of all of these disorders. Instead of assisting our health practitioner colleagues, this one-at-a-time strategy has served instead to confuse, overwhelm and frustrate. Few if any models introduced and studied in routine health care settings address co-occurring disorders.
A second major problem is the misunderstanding that is created with the insinuation that mental health or substance use problems can be significantly treated with brief and simple interventions (the SBI components of the SBIRT model). This minimizes the severity of the disorders, and potentially contributes to health care provider frustration by setting up unrealistic expectations for immediate results. In fact, evidence for the benefits of screening and brief intervention exists, but typically in low severity cases, for single problem patients, and for short term outcomes. Co-occurring disorders are not typically addressed. The work of researchers such as Stecker (2010) contribute the “RT” (referral to treatment) components of SBIRT, and recognize these as the most critical pieces for persons who have actual substance use, mental health or co-occurring disorders.
We have recently begun to field test a version of the DDCAT and DDCMHT adapted for routine medical settings. This measure, called the Dual Diagnosis Capability in Health Care Settings (DDCHCS), defines 35 policy, practice and workforce benchmarks for health centers, family practice settings, and emergency departments for developing advanced behavioral health capability.
We risk failing to capitalize on this pivotal opportunity in U.S. history by neglecting to consider the prevalence of co-occurring disorders, implementing yet again single disorder assessment and treatment approaches, and minimizing the range in severity among persons who suffer these conditions.
Question: The benefits of peer recovery support seem to be well understood for persons with substance use disorders. What about persons with co-occurring disorders?
Answer: In fact, the “power of example” in recovery for the person with a co-occurring disorder is equally important as for the person with an alcohol, drug or mental health problem. Information about and availability of peer recovery support groups for persons with co-occurring disorders, such as Dual Recovery Anonymous (DRA) or Dual Diagnosis Anonymous (DDA), are constantly emerging. Treatment programs and systems are recognizing the value of peer specialists, peer mentors, peer members on advisory and leadership boards, and utilizing volunteers in recovery. Persons with co-occurring disorders are increasingly welcome in traditional mutual support groups, such as Alcoholics Anonymous (AA) and Narcotics Anonymous. Surveys of AA membership reveal high rates of the use of psychotropic medication, and Bill Wilson, co-founder of AA, suffered a co-occurring disorder himself. The recovery perspective has been resurrected in mental health as well. There is greater identification with the positive life-change side of life, rather than simply the reduction of symptoms. Since both substance use and mental health issues continue to be stigmatized, the benefits of peer recovery support and the realization that “I am not alone” is tremendously important.