Clinical and systems barriers often stand in the way of care for cooccurring

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1 Substance Abuse With Mental Disorders: Specialized Public Systems And Integrated Care Treating co-occurring substance abuse and mental health problems in separate systems has historical precedent, but is it effective? by M. Audrey Burnam and Katherine E. Watkins ABSTRACT: Separate public financing and regulation of substance (SA) abuse treatment distinct from mental health (MH) treatment preserves a focus on the special needs of those with substance abuse but creates challenges to providing appropriate care for the large number of people with co-occurring conditions. This paper reviews recent efforts to overcome these challenges through clinical and systems approaches that better integrate care. Although much progress has been made for some subgroups of people with co-occurring disorders, further efforts to develop and sustain clinically integrated service delivery approaches within separate systems, particularly in SA treatment settings, are needed. [Health Affairs 25, no. 3 (2006): ; /hlthaff ] Clinical and systems barriers often stand in the way of care for cooccurring mental health (MH) and substance abuse (SA) disorders. In the past decade there has been much effort to overcome these barriers, including development and dissemination of integrated clinical intervention approaches, and states activities to reduce the administrative and philosophical divisions between the two treatment systems. In this paper we review progress that has been made, identify current challenges, and point to promising directions for the future. Background And Context Public SA treatment emerged in the 1970s under administrative, financing, and regulatory structures that were distinct from the MH system, which had evolved from a state psychiatric hospital system established in the 1800s to a broader system of community-based care beginning in the 1960s. 1 This exceptionalism of SA treatment from mainstream mental health is rooted in purposeful public policy in much the same way that a specialized public MH system evolved to protect the interests and respond to the special treatment needs of a vulnerable and stigmatized population with mental disorders. The SA treatment system is smaller than the Audrey Burnam (aburnam@rand.org) is a senior behavioral scientist at RAND in Santa Monica, California. Katherine Watkins is a full natural scientist there. 648 May/June 2006 DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 SA/MH Disorders MH system, and its advocacy voice is less powerful; thus, a separate administrative structure preserves distinctive treatment approaches and protects treatment priorities for the population with SA disorders. But the existence of distinct public MH and SA treatment systems has created sizable barriers to providing appropriate treatment services for people who have both kinds of disorders. 2 Only in the 1980s, as epidemiologic studies began to show the high prevalence of co-occurring disorders in both clinical and community settings, did researchers begin to grasp the magnitude of this problem. 3 Among people who have a current addictive disorder, almost half have a mental disorder, too; among people who have a current mental disorder, percent have an addictive disorder, too. 4 Early debate focused on determining which disorder was primary and thus the appropriate target of treatment; evidence now supports the view that most co-occurring disorders are independent disorders and that each condition requires treatment. 5 Around the same time, researchers began to document the ways that people with co-occurring disorders often fell through the cracks of the MH and SA treatment systems. 6 Frequently denied care in a single system because of the complexity of their co-occurring disorder, many could not obtain either type of treatment. 7 Otherswhowereabletoobtaintreatmentinasinglesystemcouldnotreceive care for their co-occurring disorder. Both poor outcomes and higher costs were documented when one disorder was treated and the other ignored. 8 Although efficacious treatments emerged as of the mid-1990s, most people with cooccurring disorders were not receiving effective treatment. 9 These problems were viewed as consequences of administrative and funding divisions between MH and SA systems at both the federal and state levels, creating nearly intractable system barriers. 10 Although public MH/SA treatment systems are the responsibility of states, they have been shaped by distinctive federal financing and different traditions of treatment philosophy, and they are administered as distinctive domains of regulation and oversight at the state level. Federal funding streams. Medicaid is the primary source of federal revenue for MH services, representing more than one-third of total public MH spending; the priority population for the public MH system those with severe mental illnesses are generally eligible for Medicaid because of disability. 11 State MH budgets are used to provide the state match to Medicaid, and many states have expanded MH services to maximally leverage federal contributions to services; as a result, state MH services are largely driven by Medicaid policy and regulation. 12 Medicaid pays for only 15 percent of SA treatment. And although most state Medicaid programs offer some SA service benefits, this coverage is optional and typically more limitedthanthatofmhservices. 13 Further, Social Security regulations prohibit eligibility for Supplemental Security Income (SSI) on the basis of SA disability; thus, many of those who need publicly funded SA treatment services are not eligible for Medicaid. States also receive federal funds through separate categorical block grants HEALTH AFFAIRS ~ Volume 25, Number 3 649

3 for MH and SA treatment services, with block grant funds representing 25 percent of total public SA treatment budgets but only a 4 percent of MH budgets. 14 As a result of Medicaid eligibility criteria, distinctive MH and SA Medicaid benefits, and categorical block-grant funding, commingling of MH and SA funds is virtually impossible, and blending of funds is a challenge. 15 Treatment philosophy. Public SA treatment models emerged from community recovery movements, which embraced the notion of rehabilitation with a supportive, self-policing community of peers (such as Alcoholics Anonymous and Therapeutic Communities). The SA treatment workforce thus includes many counseling staff with experience-based rather than formal training. This contrasts with a professional tradition of formal training and credentialing of MH service providers in academic departments of psychiatry, psychology, and social work. These distinctive origins have been associated with divergent treatment philosophies and ideologies that created distrust of MH treatments by SA providers and vice versa. 16 State administration. Given the distinctive regulatory environments for the flow of federal funding for MH and SA services, and the distinctive treatment models and provider workforce, states evolved distinctive administrative structures for the two systems. Although large state variations exist in specific organizational and administrative arrangements, publicly funded MH and SA services invariably involve separate state-level leadership, separate licensing and quality assurance standards for provider agencies, and separate management information systems to support reimbursement of services and accountability. In many states, the state-level SA and MH authorities are organizationally merged in a single state agency or are parallel organizational divisions within a single umbrella agency. However, distinctive financing and regulatory environments create challenges to unified approaches to the delivery of services even when a single state agency is in charge. Progress In Providing Care For Co-Occurring Disorders An important framework for conceptualizing the diversity of people with cooccurring disorders emerged in the 1990s; it facilitated shared terminology and a common understanding of co-occurring disorders across MH and SA administrators, providers, and other stakeholder groups. The quadrant model organizes cooccurring disorders into four subgroups, based on the severity of each disorder, and emphasizes the heterogeneity of the population (Exhibit 1). 17 Although the framework lacks empirical validity and does not reflect the reality that most people move between quadrants as symptoms fluctuate, it has been broadly accepted as a working rubric to refer to differences among co-occurring populations. The development of the quadrant model drew attention to the different systems providing care for people with co-occurring MH and SA disorders, helping promulgate the view that each of these systems has responsibility for its particular population. The model pointed out, for example, that those with severe mental disorders typically seek care in the public mental health system, while those with 650 May/June 2006

4 SA/MH Disorders EXHIBIT 1 The Quadrant Model For Understanding Co-Occurring Mental Health And Substance Abuse Disorders High severity Alcohol and other drug abuse III: Less severe mental disorder, more severe substance abuse I: Less severe mental disorder, less severe substance abuse IV: More severe mental disorder, more severe substance abuse II: More severe mental disorder, less severe substance abuse Low severity Low severity Mental illness High severity SOURCE: National Association of State Mental Health Program Directors and National Association of State Alcohol/Drug Abuse Directors, The New Conceptual Framework for Co-Occurring Mental Health and Substance Use Disorders (Washington: NASMHPD, 1998). severe substance abuse and less severe mental illnesses are typically served by the public substance abuse treatment system. Although in reality, people can and do move between systems of care somewhat independently of symptom severity, the recognition of special types of co-occurring populations belonging to each system began to change views that consumers with co-occurring disorders should be divertedoutofeithermhorsatreatmentservices. Further refinements of the model proposed different service delivery strategies corresponding to the different quadrants. Individuals in quadrant I could be served through consultation between systems; those in quadrants II and III might benefit from collaboration between systems; and those in quadrant IV might require clinically integrated services. All of these approaches have been referred to as integrated care, which, broadly defined, refers to any mechanism by which treatment interventions for co-occurring disorders are combined so that both disorders can be treated. 18 Clinical Approaches To Integrated Care Until the past decade, two general approaches to integrating MH and SA treatment have predominated: sequential and parallel treatment. Both use linkage to combine treatment services. In the sequential treatment approach, clients receive treatment for one problem, and treatment for the other problem is deferred until the first is resolved or stabilized. Provider systems link when responsibility for the client is passed from one system to the next. In the parallel treatment approach, different providers who are usually not part of the same service system treat the two disorders simultaneously. Efforts to integrate service delivery and improve access and outcomes within each approach focused on fostering cooperation between the MH and SA treatment agencies, to smooth out the non service delivery aspects of treatment. 19 Goals for service integration within parallel and sequential treatment include HEALTH AFFAIRS ~ Volume 25, Number 3 651

5 strengthening the relationship between fragmented programs, reducing philosophical barriers, agreeing on responsibilities and service eligibility criteria, and improving communication about referrals and treatment progress between independent agencies. 20 Often these efforts included cross-training providers, establishing informal policies and relationships between MH and SA treatment programs, and locating practitioners of one type of care into the other setting. Despite major efforts to improve linkages, there are disadvantages to traditional sequential and parallel treatment. 21 Philosophical differences remain, and administrative and organizational problems often preclude active collaboration between professionals from different agencies. 22 In practice, clients are often not referred for the untreated disorder or might not be eligible for services in the other system. 23 Co-occurring disorders are frequently interactive and cyclical: Substance abuse can worsen the course of psychiatric illness, and worsening psychiatric disorders can lead to increased substance abuse. Most importantly, the burden of establishing and following a coherent plan of treatment falls on the client. Improved program linkages usually do not modify the experiences of front-line workers or consumers and have not led to greatly improved access or outcomes at the national leve1. 24 Requiring clients to obtain services in different treatment systems is also at odds with the current movement toward person-centered care, which implies that access to services for both disorders should be available regardless of the initial contact point. 25 An alternative approach to improving access and outcomes has focused on integrating services at the client level. 26 Spurred by the increasing recognition of the limitations of existing service settings, this approach was designed to eliminate many of the disadvantages of traditional sequential and parallel treatment. In the best-known example of this approach (integrated dual disorders treatment, or IDDT), comprehensive services for both mental illness and substance abuse are provided simultaneously by a multidisciplinary treatment team. 27 This eliminates organizational and administrative lapses and clinical choices about which disorder is primary. Both disorders are targeted for effective diagnosis and stagespecific treatment, and a single treatment plan minimizes philosophical differences among providers. 28 Numerous studies support the effectiveness of IDDT for people with severe mental illnesses and severe substance abuse. 29 Efforts to combine substance abuse, mental health, and trauma-related issues in either individual or group counseling offer another promising example of such models. 30 Apart from IDDT, some pharmacotherapies, and behavioral SA therapies, few treatment practices for people with co-occurring disorders are supported by research-based evidence. 31 Most treatment recommendations for people with affective and anxiety disorders along with severe substance abuse are supported only by expert opinion, and much work remains to identify clinical interventions with demonstrated effectiveness and feasibility. Indeed, many treatment recommendations for co-occurring disorders are not easily evaluated for efficacy, and they lack 652 May/June 2006

6 SA/MH Disorders the specificity to be implemented consistently. It has been difficult to develop and evaluate sustainable integrated treatment models within SA systems, given scarce resources and limited workforce capacity to provide MH services. 32 System Approaches To Integrated Care Here we describe states actions to overcome administrative and philosophical barriers to providing integrated services. Our observations are based on interviews conducted in with directors of MH and SA authorities in twentythree states. These states were selected based on reports that they have undertaken activities to improve care for people with co-occurring disorders. 33 Flexible financing. To overcome the challenges of funding silos, states have developed financing strategies that can support services for co-occurring disorders integrated at the level of the provider agency. A few states use flexible block-grant funds and state dollars to provide crossover funding for co-occurring disorders. In Illinois, for example, separate state MH and SA treatment authorities provide funds to providers in the other system so that they can extend their services to include care for people with co-occurring disorders. Many states have focused on opportunities to make Medicaid funding more flexible by modifying regulations regarding specific service definitions and billing codes so that services for co-occurring disorders suchasiddtarereimbursablefortheeligiblemedicaidpopulation.thesehaveincreased opportunities to deliver clinically integrated care within the MH service system generally focused on the population with severe mental illnesses who are Medicaid-eligible. A few states have undertaken broader Medicaid program reforms that operate through contracts with managed care organization (MCO) vendors to create more flexibility to fund both MH and SA treatment services. Arizona, for example, contracts with five regional organizations to provide services to the Medicaid population under an at-risk arrangement and, for the non-medicaid poor, under a no-risk (administrative services only, or ASO) arrangement. MH and SA service benefits are the same for both populations, and provider agencies are reimbursed for both types of services by a single payer, which manages diverse funding streams and creates the impression of a seamless system from the perspective of providers and consumers. Bridging treatment philosophy differences. The states we studied have all engaged in broad consensus building and educational efforts to bridge the historical treatment-philosophy divide between MH and SA treatment providers. Often these efforts include educational conferences, community meetings, and special committees or task forces, intended to create broader stakeholder involvement and support among consumer and family advocates. Many states have sponsored broad education and training regarding current treatment principles and best practices; some have developed institutional capacities for ongoing clinical training and technical assistance. Although these activities have forged shared perspectives among stakeholders about the importance of improving services and a shared language for de- HEALTH AFFAIRS ~ Volume 25, Number 3 653

7 scribing the diversity and service needs of people with co-occurring disorders, it is unknown whether either broad or specific educational efforts result in improved clinical care and outcomes. The current evaluation of the Substance Abuse and Mental Health Services Administration (SAMHSA) toolkit initiative will help answer this. 34 Disciplinary and philosophical divides still might pose some challenges for front-line providers, but these barriers are now less prominent concerns. Administrative oversight and accountability practices. States have sometimes made changes in administrative rules or practices to facilitate delivery of services for co-occurring disorders by addressing workforce credentials/licensing and management information systems. Separate licensing requirements for MH and SA provider agencies can be a barrier to providing clinically integrated treatment. Some states have addressed this by modifying licensing regulations or other provider agency requirements. Connecticut, for example, began granting waivers to existing licensing regulation so that MH and SA treatment provider agencies could be crosslicensed. Arizona mandates that provider agencies be either dual-diagnosis enhanced, meaning that they are qualified and able to deliver both MH and SA services, or dual-diagnosis capable, meaning that they can link patients to complementary services outside their agency. Some states have developed new positions, such as co-occurring disorders coordinators, with responsibilities specifically crafted to address the fragmentation of services. Many states reported interest in developing clinician standards for co-occurring disorders, but only a few have done so. Illinois, for example, has a clinician certification program and an optional accreditation for provider agencies in co-occurring disorders competencies. Separate management information systems make it difficult to assess needs for co-occurring disorders and to measure performance of public services in meeting those needs. Most states information systems have limitations that prevent answering the most basic questions: Of those receiving MH services, how many have SA disorders? Of those receiving SA treatment and referred to MH services, how many receive care? Many states are planning or have undertaken improvements in their systems to address these limitations. Efforts include the development of standardized intake protocols that would document co-occurring disorders at entry into either MH or SA treatment facilities, making systems linkable so that peopleappearinginonesystemcanbefoundintheother,anddevelopingcommon service definitions and coding that allow comparisons across systems and data elements that specifically identify integrated co-occurring disorders services. Current Challenges Despiteprogressasoutlinedabove,majorquestionsandchallengesremainin considering treatment for co-occurring disorders. Delivering services to people in the MH system. Much progress has been made in developing and disseminating integrated services for those with severe mental illnesses and severe substance abuse who seek services largely in the MH 654 May/June 2006

8 SA/MH Disorders system. Many states have implemented versions of IDDT in at least some localities, and some are undertaking efforts to develop and offer services statewide. Implications for agency budgets and opportunities for Medicaid reimbursement are key concerns. Because most of the population with severe mental illnesses is Medicaideligible, states can rely on Medicaid financing as well as more flexible but scarce state and federal block-grant dollars to support these services. However, cost implications might be restraining broader dissemination. A key question is how much service intensity is required for IDDT to be effective. Related to this is whether the more intensive service model should be targeted narrowly to those with the most severe and chronic disorders, or expanded more broadly to those served by the public MH system, for whom there is less evidence of the model s effectiveness. Less intensive integrated service models might be equally effective and less costly for some people. 35 A particular gap is the lack of evidence-based interventions and treatment models for people with severe mental illnesses and mild-to-moderate substance abuse. Delivering services to people in the SA treatment system. Financing barriers continue to limit access to public MH services, since state MH resources are targeted to those with severe mental disorders and the Medicaid-eligible. Substance abuse is no longer a reason for disability (SSI) and associated Medicaid eligibility, and many of those in the SA treatment system are not eligible for Temporary Assistance for Needy Families (TANF) and associated Medicaid because they do not have dependent children. Thinly stretched SA treatment budgets in most states leave little capacity to enrich SA treatment with MH-related services, even though states were recently given flexibility to use the federal SA treatment block grant to fund MH services for those with co-occurring disorders. Licensing and credentialing standards in most states also prevent SA treatment providers from delivering MH services. And coordination of treatment between different SA and MH treatment providers is hampered by privacy protections and the absence of routine processes for coordinating parallel or sequential care for cooccurring disorders. In addition, the development of evidence-based services for co-occurring disorders for those who receive care through the SA treatment system has been limited. 36 Several pharmacotherapies and SA treatments show promise, but there has been little research to evaluate promising integrated service delivery models or nonpharmacologic MH treatment interventions. Early research suggests that SA treatment providers can be trained to recognize and refer clients with co-occurring disorders but that this did not result in improved outcomes. 37 Promising Directions We believe that efforts to develop clinical models that emphasize the provision of services within a single setting (for example, developing the capacity of the SA treatment system to deliver MH care, or vice versa) will have a big payoff. Linkage approaches are appealing because they require little in the way of additional re- HEALTH AFFAIRS ~ Volume 25, Number 3 655

9 sources or system change; however, they have not been successful, and they pose special challenges related to privacy and the sharing of information. Although it might be tempting to extend models such as IDDT to quadrants II and III, such intensive treatment strategies might not be necessary or feasible to implement. To develop the capacity of each system to deliver care for the other disorder, researchers need to evaluate whether effective treatment components can be readily translated to the workforce capabilities and resources of the other system. An overarching issue is to determine which treatment interventions for co-occurring disorders require which level of service coordination/combination, and which could be delivered by developing the capacity of a single service system. SA treatment counseling staff, for example, could be trained in cognitive behavioral therapy, an efficacious psychosocial intervention for affective and anxiety disorders but not yet demonstrated effective in this service delivery setting. It will require commitment on the part of state MH/SA authorities to support the use of integrative models of care within each population and setting. As noted above, financing and regulatory barriers must be overcome. Focus on the SA population and treatment setting has been limited. Broad state reforms designed to improve access to and quality of behavioral health care and to manage available resources more efficiently hold much promise for people with co-occurring disorders who rely on public-sector services. New Mexico, for example, is undertaking a reform that redesigns behavioral health care financing that was previously fragmented across fifteen state departments by contracting with a single statewide entity (a managed behavioral health care organization) and providing close interdepartmental oversight. 38 A much more radical change would involve mainstreaming of substance abuse into mental health administration at the federal level, obviating the need for states to manage the challenges of fragmented funding streams. This is not what we are suggesting. There are compelling reasons for maintaining a federal policy approach that preserves the exceptionalism for SA treatment. Evolving flexibility of federal Medicaid policy has provided opportunities to support integrated models of care for co-occurring disorders for those with serious mental illnesses within the fiscal and regulatory environment of the MH system. This has been an important step forward in addressing gaps in care for co-occurring disorders. Federal policymakers should now create opportunities for states to develop and sustain integrated models of care for co-occurring disorders within the fiscal and regulatory environment of the SA treatment system. For example, expansion of federal block-grant or Medicaid funding to pay for psychiatric medications and for MH assessment and medication management for people in treatment for severe SA disorders, is a potentially good social investment, but further research is needed to project the costs and benefits of such strategies. 656 May/June 2006

10 SA/MH Disorders The authors gratefully acknowledge support from the Robert Wood Johnson Foundation and the John D. and CatherineT.MacArthurFoundationforthisresearch.Theviewsexpressedherearesolelythoseoftheauthorsand do not necessarily reflect the views of these foundations. NOTES 1. Institute of Medicine, Managing Managed Care: Quality Improvement in Behavioral Health (Washington: National Academies Press, 1997). 2. M.S. Ridgely, H.H. Goldman, and M. Willenbring, Barriers to the Care of Persons with Dual Diagnoses: Organizational and Financing Issues, Schizophrenia Bulletin 16, no. 1 (1990): D.A. Regier et al., Comorbidity of Mental Disorders with Alcohol and Other Drug Abuse: Results from the Epidemiologic Catchment Area (ECA) Study, Journal of the American Medical Association 264, no. 19 (1990): ; D. Hasin, J. Endicott, and C. Lewis, Alcohol and Drug Abuse in Patients with Affective Syndromes, Comprehensive Psychiatry 26, no. 3 (1985): ; and H.E. Ross, F.B. Glaser, and T. Germanson, The Prevalence of Psychiatric Disorders in Patients with Alcohol and Other Drug Problems, Archives of General Psychiatry 45, no. 11 (1988): R.C. Kessler et al., The Epidemiology of Co-Occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization, American Journal of Orthopsychiatry 66, no. 1 (1996): 17 31; and Regier et al., Comorbidity of Mental Disorders. 5. Kessler et al., The Epidemiology ; R.C. Kessler et al., Lifetime Co-Occurrence of DSM-III-R Alcohol Abuse and Dependence with Other Psychiatric Disorders in the National Comorbidity Survey, Archives of General Psychiatry 54, no. 4 (1997): ; and B.F. Grant et al., Prevalence and Co-Occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions, Archives of General Psychiatry 61, no. 8 (2004): Ridgely et al., Barriers. 7. F.C. Osher and R.E. Drake, Reversing a History of Unmet Needs: Approaches to Care for Persons with Co-Occurring Addictive and Mental Disorders, American Journal of Orthopsychiatry 66, no. 1 (1996): Ibid.; B. Dickey and H. Azeni, Persons with Dual Diagnoses of Substance Abuse and Major Mental Illness: Their Excess Costs of Psychiatric Care, American Journal of Public Health 86, no. 7 (1996): ; and R.A. Hoff and R.A. Rosenheck, The Cost of Treating Substance Abuse Patients With and Without Comorbid Psychiatric Disorders, Psychiatric Services 50, no. 10 (1999): K.T. Mueser et al., Integrated Treatment for Dual Disorders: A Guide to Effective Practice (New York: Guilford Press, 2003); K.E. Watkins et al., Review of Treatment Recommendations for Persons with a Co-Occurring Affective or Anxiety and Substance Use Disorder, Psychiatric Services 56, no. 8 (2005): ; and K.E. Watkins et al., A National Survey of Care for Persons with Co-Occurring Mental and Substance Use Disorders, Psychiatric Services 52, no. 8 (2001): Ridgely et al., Barriers. 11. R.G. Frank et al., Paying for Mental Health and Substance Abuse Care, Health Affairs 13, no. 1 (1994): R.G. Frank, H.H. Goldman, and M. Hogan, Medicaid and Mental Health: Be Careful What You Ask For, Health Affairs 22, no. 1 (2003): M. Maglione and M.S. Ridgely, Is Conventional Wisdom Wrong? Coverage for Substance Abuse Treatment under Medicaid Managed Care, Journal of Substance Abuse Treatment (forthcoming). 14. M.A. Burnam et al., Review and Evaluation of the Substance Abuse and Mental Health Services Block Grant Allotment Formula, Pub. no. MR-533-HHS/DPRC (Santa Monica, Calif.: RAND, 1997). 15. Osher and Drake, Reversing a History ; and M.S. Ridgely and L.B. Dixon, Policy and Financing Issues, in Double Jeopardy: Chronic Mental Illness and Substance Use Disorders, ed.a.f.lehmanandl.dixon(chur,switzerland: Harwood Academic Publishers, 1995), Osher and Drake, Reversing a History. 17. National Association of State Mental Health Program Directors (NASMHPD) and National Association of State Alcohol/Drug Abuse Directors (NASADAD), The New Conceptual Framework for Co-Occurring Mental Health and Substance Use Disorders (Washington: NASMHPD, 1998); and R.K. Ries and N.S. Miller, Dual Diagnosis: Concept, Diagnosis, and Treatment, in Current Psychiatric Therapy, ed. D.L. Dunner(Philadelphia: W.B. Saunders Company, 1993), HEALTH AFFAIRS ~ Volume 25, Number 3 657

11 18. Center for Substance Abuse Treatment, Substance Abuse Treatment for Persons with Co-occurring Disorders, TreatmentImprovementProtocol(TIP)Series42,Pub.no.(SMA) (Rockville,Md.:SubstanceAbuse and Mental Health Services Administration, 2005). 19. CSAT, Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse, TIP Series 9, Pub. no. (SMA) (Rockville, Md.: SAMHSA, 1994). 20. K.E. Watkins et al., Prevalence and Characteristics of Clients with Co-Occurring Disorders in Outpatient Substance Abuse Treatment, American Journal of Drug and Alcohol Abuse 30, no. 4 (2004): ; S.B. Hunter et al., Training Substance Abuse Treatment Staff to Care for Co-Occurring Disorders, Journal of SubstanceAbuseTreatment 28, no. 3 (2005): ; and K. Minkoff and C. Ajilore, Co-OccurringPsychiatricand Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula, 1998, (accessed 15 February 2006); and Annotated Bibliography, CooccurringBib.pdf (accessed 15 February 2006). 21. Mueser et al., Integrated Treatment. 22. D.J. Kavanagh et al., Contrasting Views and Experiences of Health Professionals on the Management of Comorbid Substance Misuse and Mental Disorders, Australian and New Zealand Journal of Psychiatry 34, no. 2 (2000): Hunter et al., Training Substance Abuse. 24. S.L. Kagan and P.R. Neville, IntegratingServicesforChildrenandFamilies:UnderstandingthePasttoShapetheFuture (New Haven, Conn.: Yale University Press, 1993); and Watkins et al., A National Survey. 25. IOM, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001). 26. Mueser et al., Integrated Treatment; and Kagan and Neville, Integrating Services. 27. Center for Mental Health Services, Co-occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit (Draft Version), 2003, IDDTUsersguideAJ1_04.pdf (accessed 15 February 2006). 28. Mueser et al., Integrated Treatment. 29. K.T. Mueser et al., Psychosocial Interventions for Adults with Severe Mental Illnesses and Co-Occurring Substance Use Disorders: A Review of Specific Interventions, Journal of Dual Diagnosis 1, no. 2 (2005): 57 82;andM.F.Brunette,K.T.Mueser,andR.E.Drake, AReviewofResearchonResidentialProgramsfor People with Severe Mental Illness and Co-Occurring Substance Use Disorders, Drug and Alcohol Review 23, no. 4 (2004): J.P. Morrissey et al., Twelve-Month Outcomes of Trauma-Informed Interventions for Women with Co- Occurring Disorders, Psychiatric Services 56, no. 10 (2005): Watkins et al., Review of Treatment. 32. Hunter et al., Training Substance Abuse ; and S.L. Wenzel et al., A Collaboration between Researchers and Practitioners to Improve Care for Co-Occurring Mental Health Disorders in Outpatient Substance Abuse Treatment (Santa Monica, Calif.: RAND, 2005). 33. H.A. Pincus et al., State Efforts to Improve Practice and Policy for Individuals with Co-Occurring Mental and Addictive Disorders, Pub. no. WR-344-RWJ (Santa Monica, Calif.: RAND, 2006). 34. New Hampshire Dartmouth Psychiatric Research Center, Evidence-based Practices and Knowledge Dissemination Projects, 30 November 2004, (accessed 15 February 2006). 35. Mueser et al., Psychosocial Interventions for Adults. 36. Watkins et al., Review of Treatment. 37. Hunter et al., Training Substance Abuse ; and Wenzel et al., A Collaboration between Researchers. 38. P.S. Hyde, State Mental Health Policy: A Unique Approach to Designing a Comprehensive Behavioral Health System in New Mexico, Psychiatric Services 55, no. 9 (2004): May/June 2006