Co-occurring disorders need integrated treatment
Co-occurring disorders need integrated treatment
Cross-training is key to recognizing dual needs
Patients seeking treatment for substance addiction or mental illness already face a very challenging road to recovery, but almost half of these people do not get the treatment they need for both illnesses.
Faced with what is known as a "dual diagnosis" or "co-occurring" disorder, such patients are often misdiagnosed, don’t receive appropriate treatment, and are at an increased risk for homelessness or incarceration, advocates say.
"There are two distinct systems of care for either addiction or mental illness," says Michael Cartwright, executive director of Foundations Associates in Nashville, TN, a residential treatment program for patients with co-occurring disorders, which also administers the Dual Diagnosis Recovery Network (DDRN), an organization dedicated to providing education and advocacy for these patients.
"You have different trained professionals with different licensure systems and different funding streams from the federal and state governments," Cartwright continues. "Most states have separate governing bodies for mental health or substance-abuse treatment programs — there are really two separate systems of care."
Services divided at hospital level
Most acute-care facilities have either a substance-abuse treatment unit or mental health unit, Cartwright explains. If the hospital has both, they are not integrated, and patients in one program may not get needed services from the other.
"Especially in the mental health field, many providers looked at it [a co-occurring substance addiction] as a secondary diagnosis, and that is not really accurate," he explains. "If people present in the ER [emergency room] with a broken arm and broken foot, both are considered primary, separate diagnoses. They both need treatment."
But depending on the provider’s training and background, he or she may not recognize the other coexisting disorder.
"Most mental health professionals do not get very much formal education about addiction. Social workers, psychologists, even psychiatrists get very little formal training in addiction disorders," Cartwright says.
And people trained to work with substance addiction often do not have the skills to appro-priately diagnose a mental illness or even make an appropriate mental health referral.
"If they have a patient, they may not even screen for it or pick up on it," Cartwright continues. "And, a lot of primary care doctors, when they see people in ERs or in a clinic, are not picking up on the fact that this person has an addiction."
Conflicts in treatment methodologies
Mental health professionals and substance abuse treatment providers often do not "talk" to each other, with the result that patients with co-occurring disorders often receive treatment plans that conflict and contradict each other, says Cecelia Vergaretti, vice president of community services and advocacy for the National Mental Health Association (NMHA) in Washington, DC.
"Treatment issues and philosophies can be very different," she says. "Some substance-abuse treatment providers will say you have to have abstinence, whereas in the mental health field, recovery is seen as a journey with many ups and downs."
If a patient is diagnosed with both schizophrenia and a drinking problem, that person may need certain medication but then also be told by an alcohol recovery program to avoid all controlled substances.
"There really needs to be a community dialogue among people with co-occurring disorders and people who provide treatment," says Vergaretti.
Improving education, cross-training for different groups of providers, and integration of services are the keys to improving the system, say both Vergaretti and Cartwright.
"We are trying to move toward a system in which there is no wrong door,’" Cartwright says. "No matter which door you walk through, the mental health door or addiction door, you will get the appropriate diagnosis and follow-up."
A good step would be for health systems to integrate their substance addiction and mental health treatment programs into an behavioral health unit, he adds.
National studies indicate that more than half of patients diagnosed with a substance addiction have a coexisting mental illness, and approximately the same numbers of those diagnosed with mental illness have a coexisting addiction problem, Cartwright explains.
Such significant numbers demand better integration of services, he feels. Although the need will remain for specialty, single-diagnosis tracks within behavioral health units, the need for an integrated program is great.
However, improved provider education is needed to support such a system, he advises. When the DDRN has attempted to establish integrated treatment systems in areas where it offers residential services, they found it took a lot of initial training of providers to get the system off the ground.
"First, we need mental health providers trained in addiction," he notes. "Not just one course over a four-year period, but continuing education about how to assess. Then, we need to have integration of services."
More efforts at state and national level
Fortunately, there has been more movement at the legislative and governmental level to improve the system of care for patients with co-occurring disorders.
The U.S. Substance Abuse and Mental Health Services Administration, a division of the Depart-ment of Health and Human Services, is preparing a report to Congress on co-occurring disorders that is expected to be released on Oct. 14, says Cartwright.
And state public health systems are beginning to develop plans to integrate funding and systems of care, reports Vergaretti.
In 1998, the National Association of State Mental Health Program Directors and National Association of State Alcohol and Drug Abuse Directors held a meeting to discuss co-occurring disorders and developed a framework of recommended treatment, administrative, and funding changes needed to improve the situation. The framework has been published as the National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders.
For providers seeking more information, the NMHA also has published a fact sheet on dual diagnosis, and the DDRN maintains a resource library of journal articles and other publications on its web site at www.dualdiagnosis.org.
Sources
- Cecelia Vergaretti, 1021 Prince St., Alexandria, VA 22314-2971.
- Michael Cartwright, 220 Venture Circle, Nashville, TN 37228.
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