Organizational guidelines for dual disorders programs

Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities

OBJECTIVE

To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions.

METHOD

We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits.

RESULTS

Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy.

CONCLUSION

In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.

The challenge of psychiatric comorbidity to the public services for drug dependence in Italy: A national survey

We evaluated the availability of resources and specific expertise for treating comorbidity at the Italian public Services for Drug Dependence (SerTs). A stratified sample of 100 SerTs was constructed and a specific questionnaire mailed to the clinical managers. The interview aimed at: characteristics of the respondent; theoretical knowledge of comorbidity; influence of dual diagnosis on clinical practice; general, human, and organisational resources; quality evaluation.

MAIN RESULTS

(a) 90% of managers are medical doctors but <50% have a specialisation in psychiatry or qualification in psychotherapy; (b) about half of the managers have a fair knowledge of comorbidity; (c) the managers' estimate of prevalence is 25% for Axis I and 25-50% for Axis II comorbidity, and they consider the bad course of illness as the main cause of increased costs; (d) the SerTs' resources appear incomplete: psychiatric consultation and collaboration with therapeutic communities are available in about 90%, but routine assessment of psychopathology and day hospital or day care programs are lacking in over 50%; (e) about half of the managers declare themselves fairly satisfied about the treatments offered, but 80% complain about inadequate cooperation of the mental health services and >95% claim about inadequate education of their staff. The results were also analysed by factors of stratification: regional distribution, urban/rural location, and number of clients in care. In conclusion, the problem of comorbidity should be faced more effectively, particularly by means of improved organisational resources and continuing education of staff members.

Treating substance abuse in the context of severe and persistent mental illness: clinicians' perspectives

Patients with comorbid substance use and major mental disorders are treated frequently in the mental health system. Treatment models relevant for this subset of patients have emerged in recent years, however, few have been validated empirically and so relatively few sites benefit from this treatment development activity. Important additional sources of information about good treatment practices are the clinicians who have adopted the treatment of patients with dual disorders as a specialty. We conducted four focus groups (N = 12) with clinicians who were nominated by their peers as experienced and/or expert in treating persons with comorbid substance use and psychiatric disorders. Discussions followed a four-part outline that included (a) general questions about training and experience with the population, (b) preferred treatment methods, (c) motivational issues, and (d) recommendations to the field. Participants were trained in a variety of mental health disciplines and pursued substance abuse treatment credentials or other educational experiences outside of their primary training programs. Their treatment approaches emphasized psychoeducation, a good therapeutic relationship, and the need to be flexible regarding methods and goals. Abstinence was the preferred goal among most clinicians; even so, they expressed a pragmatic flexibility and other views consistent with the principles of harm reduction. Clinicians tended to respond to patients' ambivalent motivational states by addressing the consequences of behaviors in a nonconfrontive style; they also made use of positive incentives and external support. A number of recommendations were made to improve treatment, including greater institutional and programmatic support for the unique needs of this population.

Integrated drug and alcohol intervention: development of an opportunistic intervention program to reduce alcohol and other substance use among psychiatric patients

OBJECTIVE

This paper describes the rationale, aims and processes involved in developing and implementing an opportunistic intervention program to reduce substance misuse detected among psychiatric patients.

METHOD

In this randomised, opportunistic intervention program, eligible patients recruited from a large psychiatric hospital and its associated community mental health centres are assigned to receive an integrated drug and alcohol intervention (IDAI) or alternatively allocated to a minimal intervention condition (MI). The IDAI is based on motivational enhancement and cognitive-behavioural principles, and incorporates harm-reduction approaches. This clinical program is based on the research findings and recommendations of the mental health and the drug and alcohol literature.

RESULTS

A collaborative partnership between the Mental Health Services and the Drug and Alcohol Services was formed. Following a relatively short training period, mental health staff were trained to opportunistically detect drug and alcohol problems among psychiatric patients and offer appropriate integrated clinical care.

CONCLUSION

The process of implementing an integrated opportunistic intervention program is achievable and can be readily incorporated in psychiatric hospitals and community mental health clinics.