Summary Report of The Workshop on Best Practices for Concurrent Mental Health and Substance Use Disorders

Overview of The Best Practices - Concurrent Mental Health And Substance Use Disorders By Dr. Brian Rush

a) Definition of Concurent Disorders

In developing the report, the consensus on how to classify concurrent disorders was a challenge. It was decided that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), system of classification would be used as it provides a framework for diagnosis and this is essential for proper treatment planning. Concurrent disorder, then, means the co-occurrence of at least one mental disorder and at least one abuse of, or dependence on, a substance, as defined by the DSM-IV.

From a clinical point of view, mental health and substance abuse can be worlds apart, yet experience shows a strong overlap. For example, alcohol dependence is 21 times more likely to occur among people with antisocial personality disorder; alcohol dependence is four times more likely to occur among people with schizophrenia; and of those treated for alcohol-related disorders, up to 70 to 80 percent may have a mental disorder.

Dr. Rush pointed out the strong need for psychosocial supports, in particular for those people with severe and persistent mental illness and substance use disorders. Beyond acute treatment and medication management, long-term positive outcomes require a broad psychosocial approach, including housing, employment, income and a social support network.

b) Best Practices - Screening

Dr. Rush noted that mental health services should apply universal screening practices for substance use disorders, while substance abuse services should apply universal screening practices for mental health disorders. He stressed that the approach and tools must be tailored to the setting, time available for the client and resources available. As stated below, screening for both substance abuse and mental health may need to take place at more than one level of effort to identify whether a problem exists.

Level of Effort I - Screening for Substance Use Problems

• "Index of Suspicion" - problems such as violence, self-harm or non-compliance with treatment may trigger a suspicion of substance use and warrant further questioning.
• Clinicians should ask straightforward questions concerning alcohol and other drug use.
• Brief screening tools such as CAGE/CAGE-AID can be built into the interview discussion (AID incorporates alcohol and drugs).
• Case manager's judgment can be key.

Level of Effort II - Screening for Substance Use Problems

• Dartmouth Assessment of Lifestyle Instrument (DALI)
• Michigan Alcoholism Screening Test (MAST)
• Drug Abuse Screening Test (DAST)
• Alcohol Use Disorders Identification Test (AUDIT)

Level of Effort I - Screening for Mental Health Disorders

• "Index of Suspicion": ABC (Appearance, Alertness, Affect, Anxiety - Behaviour - Cognition) checklist. Refer to page 36 of the report for the complete checklist.
• Clinicians should ask simple questions (refer to page 37 of the report).

Level of Effort II - Screening for Mental Health Disorders

• There is a need for a solid mental health screening tool for substance abuse services. Some promising tools are currently under development.

c) Best Practices - Assessment

• The diagnosis will distinguish between the substance use and the mental illness - Structured Clinical Interview for Axis DSM-IV Disorders (SCID-IV).
  
  
• Clinician-rating scales, such as the Alcohol Use Scale or Drug Use Scale for the severely mentally ill, have been shown to be effective.
  
  
• The Addictions Severity Index should be used with caution, as its reliability with those with severe mental disorders is not as high as with other populations.
  
  
• Motivation and the stage of change should be assessed; however, it can be affected by the particular disorder (e.g., mania can lead to high confidence and energy levels).
  
  
• Psycho social functioning should be assessed through tools such as Person-in-Environment System (PIE) or Global Assessment of Functioning Scale (GAF).

d) Feedback from the Participants on Screening and Assessment

"Clients don't compartmentalize their problems; practitioners shouldn't either."

• The client must be intimately involved in the screening and assessment processes.
  
  
• Professional processes should be adapted to the client's culture.
  
  
• A single individual, perhaps a "wellness worker," should do intake and screening to increase coordination.
  
  
• Recognition that the screening processes may differ, depending on whether the purpose is for further assessment or to begin treatment is important.
  
  
• There needs to be cross-community agreement and education on key elements of assessment, including a harm reduction approach.
  
  
• Health care providers and employees should be engaged in cross training of both disciplines regardless of their current skills or training.
  
  
• Stigma can be decreased if assessment is part of an overall screening process.
  
  
• People should be made aware of the various levels of interventions available in the community, beyond institutionalization.
  
  
• Advocacy on behalf of clients can help to bridge the gap between the mental health and the substance abuse sectors.
  
  
• Any screening tools used should be included in the assessment, across mental health and substance abuse systems.
  
  
• Telemedicine and mobile community treatment teams may overcome the problems of rural or isolated offices.
  
  
• Collaborative assessment is important, using clinical teams, case conferencing and/or reflecting teams, across agencies and departments.
  
  
• Clearly outlining the treatment plan for concurrent disorders, with clear roles and identified responsibilities, is needed.
  
  
• The importance of the different approaches (e.g., self versus agency referral) used by the mental health and substance abuse sectors, and the needs of different communities (e.g., rural or those with few resources) should be recognized.
  
  
• Information sharing and open flow of communication between the two fields is key.
  
  
• Support from the ministry level is key for training. If front-line workers are the only ones working at integration, it won't work.
  
  

"Counseling is not new - it has been around for a long time. The first Inuit counselors were elders and grandparents. Once it became a profession, it became very complicated. Systems started getting in the way. Anything new must be put in the perspective of the client."