Report to Congress - Nov 2002
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REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE DISORDERS AND MENTAL DISORDERS |
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The ability to provide the most effective and coordinated range of services for people with co-occurring substance abuse disorders and mental disorders is complicated by a number of factors: the traditional philosophical, financial and administrative separation between the mental health services and substance abuse treatment systems (SAMHSA, 1997); policy barriers, funding barriers, program barriers, clinical barriers, and consumer and family barriers (Drake, Essock et al., 2001; Ridgely, Goldman & Willenbring 1990).
Key SAMHSA constituents regard policy barriers as a major impediment to the provision of effective care (The National Council and SAAS, 2002; SAMHSA 2002f). At the Federal level, they have identified insufficient coordination between Federal agencies and conflicting statutory requirements and regulations. Further, at the State level, impediments related to training and certification discourage clinicians from seeking joint credentials for professionals who serve individuals with co-occurring disorders or joint licenses to programs that offer both substance abuse and mental health services (CSAT, unpublished document; Drake, Essock et al., 2001). At the community level, zoning ordinances may permit one type of facility but not the other. Finally, most substance abuse and mental health treatment systems - whether Federal, State or local levels - collect their own unique data, and there often are no shared assessment tools to help determine the exact nature and extent of substance abuse disorders and mental disorders (NASMHPD/NASADAD, 1999).
Mental health and substance abuse treatment are funded through a patchwork of separate Federal, State, local, and private funding sources. The need to fund services for co-occurring disorders from these multiple, disparate programs may place the burden of aggregating funds on providers. As noted in Chapter 2, the Substance Abuse Prevention and Treatment (SAPT) Block Grant is the single largest source of State expenditures for public substance abuse prevention and treatment services, representing 40 percent of such expenditures. The Community Mental Health Services (CMHS) Block Grant represents between 3 and 4 percent of State expenditures for community-based mental health care. The bulk of public mental health services are paid for with State and other Federal dollars, including Medicaid. Medicaid spends approximately $20 billion per year on mental health services and approximately $1 billion annually for drug and alcohol treatment services. Other funding sources that form part of the patchwork may include private health insurance, as well as dollars from other service sectors - education, criminal justice, and child welfare.
Medicaid
During the written and verbal public input sessions, SAMHSA constituents cited State-based Medicaid policies as a significant barrier to providing comprehensive services for people with co-occurring disorders (SAMHSA, 2002f). Medicaid programs vary from State to State in the types of substance abuse treatment programs and mental health services they fund. Few providers have control over how Medicaid services are reimbursed or administered (Drake, Essock et al., 2001).
Coverage Gaps
The patchwork of funding mechanisms and disparities in coverage can create gaps in the availability of needed services. For example, existing funding streams often do not cover the so-called "wraparound" supports, such as transportation, childcare, and vocational training. Yet these ancillary services may be among the most cost-effective means of improving treatment outcomes (CSAT, unpublished document). Individuals with no insurance or inadequate coverage may be unable to afford the newer, and in many cases more effective, antipsychotic medications. Though people with co-occurring conditions are likely to be among those with the least resources, funding problems are not limited to people who are indigent or served in the public sector.
Lack of Resources
The insufficiency of service system dollars and trained professionals to provide care means there is also a significant gap in the ability of both systems to treat people in need. A new analysis of trends in health care spending reveals that expenditures for mental health services and substance abuse treatment represented 7.8 percent of the more than one trillion dollars in all U.S. health care expenditures in 1997, down from 8.8 percent of the total in 1987 (SAMHSA, 2000).
This decline occurred despite the persistent gap between the prevalence of substance abuse disorders and mental disorders and treatment use. Estimates suggest that while about 20 percent of the U.S. population is affected by mental disorders in any given year, only one-third of people in need of mental health treatment receive it (U.S. DHHS, 1999b). When it comes to substance abuse disorders, between 13 million and 16 million people need treatment for alcoholism and/or drug abuse in any given year, but only 3 million (20 percent) receive care (SAMHSA, 2000). To help improve the substance abuse treatment capacity, the President has committed $1.6 billion over the next 5 years to reduce drug use, build treatment capacity, and increase access to services that promote recovery.
At the local level, providers often lack service models, administrative guidelines, quality assurance procedures, and outcome measures to implement a full range of needed services for people with co-occurring disorders (Drake, Essock et al., 2001). Perhaps one of the most significant program-level barriers, noted by consumers and family members as well as by providers during the public input sessions, is the lack of staff trained in treating co-occurring disorders (SAMHSA, 2002f). A significant focus of public attention was around opportunities for cross-training of staff and availability of staff trained in areas of co-occurring disorders. Despite an increasing body of evidence affirming the importance of integrating mental health and substance abuse treatment, few educational institutions teach this approach (The National Council and SAAS, 2002; Drake, Essock et al., 2001).
Education of new clinicians and supervisors is important, but so, too, are efforts to retrain current clinicians and supervisors (IOM, 2000). Program administrators cite lack of funds for training and the difficulty of working across systems to cross-train providers as significant barriers (Ridgely et al., 1990). In addition, few incentives exist in the current system to motivate clinicians to become cross-trained (CSAT, unpublished document; Drake, Essock et al., 2001). They may be reluctant to diagnose a disorder for which reimbursement is unavailable, especially in cost-cutting environments that discourage more intensive care.
Clinicians who work with people with co-occurring disorders must have sufficient knowledge of a discipline in which they were not trained to be both comfortable and capable. While the fundamental approach to clinical education has not changed appreciably since 1910 (IOM, 2000), the demands on clinicians have changed dramatically. They are asked to do more in less time with fewer resources and to incorporate best practices into their work. Further, cross-training is hampered by the fact that substance abuse and mental health providers often have very different philosophies and treatment approaches (Drake, Essock et al., 2001). The result is a training gap that "leaves graduate students, working professionals, and other direct care providers inadequately prepared for practice in the current health care environment" (Hoge, 2001).
Providers in both systems have to tailor their approach to the special needs of people who have co-occurring disorders. For example, in substance abuse settings, mental health services for individuals with co-occurring substance abuse disorders focuses on educating individuals about their mental illness, engaging and persuading them to address their mental health problems, and helping them manage medications they may need to address their psychiatric symptoms. In addition, the substance abuse counselors tailor their approach to the special needs of people who have a mental disorder, including serious mental illnesses. Much of substance abuse counseling occurs in groups while mental disorders often occurs in individual sessions. In mental health service settings in contrast, providers must be able to identify substance abuse problems, assess their severity, and plan appropriate treatment based on knowledge of the interaction of the mental illness and substance abuse disorder.
Despite the fact that, historically, the mental health and substance abuse approaches to care have been different, principles of care within the two fields converge in several key areas: respect for the individual, engagement of those who are most difficult to reach, belief in the human capacity to change, and the importance of community, family, and peers to the recovery process (Osher, 1996). The substance abuse field has contributed the concept of recovery, now increasingly a focus of mental health treatment, and clinicians in both systems see the conditions they treat as chronic disorders that require long-term support.
Key barriers to treatment for individuals with co-occurring disorders are perceptions by them and their families. The following highlights major obstructions that may result in ineffective care or a decreased desire to receive care.
The stigma that is still associated with substance abuse disorders and mental disorders remains a significant barrier to the receipt of appropriate mental health services and substance abuse treatment (CSAT, in press; CSAT, 2000; U.S. DHHS, 1999b). Individuals with co-occurring substance abuse disorders and mental disorders bear a double burden.
In addition, consumers and their families often lack accessible information about the interaction of substance abuse disorders and mental disorders and the availability of effective treatment. People with serious mental illnesses may deny or minimize problems related to substance abuse or believe that substance use helps alleviate psychiatric symptoms (Drake, Essock et al., 2001). Because even limited use of substances of abuse may create significant problems for people who have serious mental illnesses, individuals, family members, and providers may not recognize the extent of the problem. People whose substance use precipitates psychiatric symptoms may be in denial about both problems.
Further, treatment of an individual in the context of his or her family helps the household as a whole realize improvement and decreases the likelihood that mental illness and substance abuse will become an ongoing pattern. However, even if family treatment is prescribed, coordinating appropriate services for adults and children is difficult because care and funding mechanisms are separate.
Consumers who provided guidance in the development of this report cited additional barriers, as well. They spoke of a low level of cultural competence among providers, which sometimes led to inappropriate diagnoses; programs that ended too soon, "dropping" them just as they were beginning to lead stable lives; restrictive eligibility criteria that favored individuals who are severely ill at the expense of people who are less ill but no less in need of treatment; and lack of involvement of consumers in their own care.