Best Practices - Concurrent Mental Health and Substance Use Disorders

Background, Definitions and Approach

Background to the Report

Within the last two decades the co-occurrence of addiction and mental health problems among people seeking treatment and support has emerged as an important issue for those who plan and fund mental health and addiction programs, as well as those people who provide direct service. Concerns about concurrent disorders have been fueled by research showing the high prevalence of such co-morbidity and its implications for the course, cost and outcome of treatment and other support services.

In response to this growing concern, and the urgent need for wider use of research-based treatment and community support strategies, Health Canada issued a Request for Proposals (RFP) for the development of best practice guidelines for the treatment and rehabilitation of individuals with concurrent substance use and mental health disorders. The RFP also called for the development of a national inventory of specialized concurrent disorders programs. This inventory, entitled "National Program Inventory - Concurrent Mental Health and Substance Use Disorders", is published separately as a companion to this document.

Concurrent Disorders are a Recognized Priority

Considerable work in Canada and elsewhere has set the stage for the development of best practice guidelines for concurrent disorders. The general framework for community integration for people with severe mental illness has been supported at the national level,^1,2 and in several provincial initiatives. Within this general framework of community treatment and support, most of the individual provinces and territories have sponsored work leading to specific program and policy recommendations. For example:

• The "Comité permanent de lutte à la toxicomanie" of the Québec Government placed comorbidity as a priority in its recommendations to the provincial government in both 1996 and 1997.^3,4 In consultations held throughout the Province of Quebec in 1995 and 2000, concerns were expressed about concurrent disorders within all age groups;^5,6
• In Ontario, individuals with concurrent disorders have been identified as a priority population by both the addictions and mental health service delivery systems.^7-9
• An Inter-ministry Task Group in British Columbia was formed to investigate how to improve services for individuals who have a severe mental illness and substance use disorder. The resulting report¹⁰ recommended several complementary approaches for the development of improved services for people with concurrent disorders.

Separate national initiatives have developed best practice guidelines for mental health services and supports,¹¹ and substance abuse treatment.¹² Practice guidelines have also been published in the peer-reviewed literature for specific disorders, such as depression,¹³ schizophrenia,^14-16 alcohol, cocaine and opioid use disorders¹⁷ and nicotine dependence.^18,19 Guidelines have also been developed for psychiatric evaluation.²⁰

Some of these practice guidelines, such as the Canadian guidelines for the treatment of schizophrenia,¹⁶ and the guidelines for psychiatric evaluation,²⁰ include recommendations for treating and supporting people with co-occurring substance use disorders. Further, the best practice literature for mental health disorders provides many recommendations for optimal treatment methods, including pharmacological interventions, that will apply to people with psychiatric problems with or without a concurrent substance use disorder. Walker et al.²¹ give an overview of developments in the substance abuse field concerning best practice guidelines, including the work by:

• the American Psychiatric Association;
• the American Nurses Association;
• the National Association of Social Workers in the U.S.;
• the well-known placement criteria of the American Society of Addiction Medicine;²²
• the Treatment Improvement Protocols (TIP) published by the Center for Substance Abuse Treatment;²³ and
• various international efforts.

As with similar work in the mental health field, many of these recommendations may apply to people in substance abuse treatment with or without concurrent disorders.

It is also important to note that planning, policy development and funding bodies in other jurisdictions have also called for the synthesis of research and clinical opinion regarding the development of best practice recommendations for people with concurrent disorders. For example, the Center for Substance Abuse Treatment (CSAT) in the U.S. commissioned a Treatment Improvement Protocol (TIP) in 1994 concerning the assessment and treatment of people with co-existing mental illness and alcohol and other drug abuse.²⁴ Given the similarity in goals between the TIP project and the current project, the results from this previous work have been valuable for this undertaking.

One important aspect of the previous work done to date has been the recognition of the importance of system-level* factors in meeting the needs of people with concurrent disorders.²⁷ This includes the need for better coordination of services across networks of mental health and substance abuse treatment providers. The importance of better integrating mental health and substance abuse services at the systemic level has been highlighted in several reports.^28-30 Systemic issues are considered in some detail in Section 4.

The Rapidly Growing Literature

In summary, there is no shortage of ideas and discussion about the needs of people with co-occurring mental health and substance use disorders, and how these needs might most effectively be met. Relevant research also continues to be undertaken and reported at a rapid rate. In addition to the better quality of individual research projects over the past decade, several excellent and highly relevant books and literature reviews have been published in the past few years.^34-41 A program manual on MICA (mentally ill-chemical abuse) by Kathleen Sciacca is available⁴² and there is at least one internet list serve on the topic (http://users.erols.com/ksciacca). Recently, an issue of Clinical Psychology Review⁴³ was dedicated to the topic of concurrent disorders, with separate articles providing a review on concurrent substance use disorders and specific mental health disorders (e.g., personality disorders; mood and anxiety). A new book by Mueser and colleagues⁴⁴ will soon be published and it provides the most recent summary of work on concurrent substance abuse and severe mental illness (e.g., schizophrenia, bipolar illness). Recent work by Mueser and colleagues⁴⁵ also provides an excellent review of etiologic theories about the interaction of substance abuse and severe mental illness.

The present project provides an updated synthesis of the research information and offers specific recommendations for the screening, assessment, and treatment/support of this in-need population based on the highest quality research information that is available. This research synthesis has been combined with the advice and input of experts and other key stakeholders in the field, including consumers who have experienced the severe consequences of concurrent disorders. This synthesis is best seen as complementing the considerable amount of work that has proceeded the project and the reader is encouraged to examine the key resource material drawn upon. To complement the list of references at the end of the report, the particularly important resource material are listed in Appendix A.

Intended Audience

This report is intended to be a resource to managers and staff of mental health, addictions and integrated mental health/substance abuse services, as well as individual practitioners in the community who are faced with the challenges of providing good quality service to people presenting with concurrent disorders. In addition, the report is targeted at planners, community developers, and other decision-makers that work at a more systems level.

* System level, as definited by Longest²⁵, and used by Aday et al.,²⁶ refers to the "resources (money, people, physical infrastructure and technology) and the organizational configurations used to transform these resources into health care services in a given geographic area".