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Keys to Successful Dual-Diagnosis Programs

Treatment programs for the millions of Americans who have comorbid mental and substance abuse disorders can be expanded successfully, though hurdles have to be overcome.

Some 10 million Americans are estimated to have both a mental illness and a substance abuse disorder, yet many of them do not receive help for either condition, let alone both. Nonetheless, a number of professionals around the United States are managing to provide combined treatment to individuals with these comorbid disorders—and with impressive results in some cases.

So the federal Substance Abuse and Mental Health Services Administration, in concert with two organizations concerned with dual-diagnosis treatment—the State Associations of Addiction Services and the National Council for Community Behavioral Healthcare—brought some of these professionals together to find out how they have done it. The results are available in a new report titled "Strategies for Developing Treatment Programs for People With Co-Occurring Substance Abuse and Mental Disorders." Here are some of the highlights of the report:

• One good way to establish a dual-diagnosis treatment program is to build gradually on an existing mental illness treatment program or vice versa rather than starting a new program from scratch. For instance, a residential treatment program for people with substance abuse problems started accepting people with co-occurring disorders, but only one diagnosis at a time. Once staff learned what they needed to know to help each population effectively, they gradually added people with other diagnoses.

• Another advantage to establishing a combined treatment program in steps is that it makes it easier to overcome different licensing requirements for certain staff at substance abuse and mental illness treatment facilities. For instance, a program of combined treatment might be wise to first employ both certified mental health counselors and certified substance abuse counselors, then later help them become dually certified.

• Whenever a substance abuse treatment program and a mental illness treatment program decide to join forces, the collaboration will have a greater chance of success if they are located close to each other. In fact, as the report points out, "Programs enjoyed more success when staff, clients, and treatment areas were geographically close together. They were least successful when staff and/or clients had to travel to different locations for various services—even when they were merely on different floors of the same building."

• Providing on-site psychiatric consultation and treatment can be crucial for the success of integrated treatment programs. "More access and availability problems arose when psychiatrists had to go ‘out of the way’ to provide treatment," the report declares. "For instance, one program using psychiatrists from a hospital four miles away had difficulty maintaining regular psychiatric services for clients with co-occurring disorders. The situation changed when the program moved across the street from the hospital."

• When a combined treatment program collects data about the patients it treats, it can use the data to expand its services. For example, some integrated treatment programs documented the relapse rates of patients before and after treatment, found that treatment reduced relapse rates, and then used the results to seek more funding.

• Medicaid—a primary funding source for most public-sector dual-diagnosis treatment programs—provides greater financial support for mental disorder treatment than for substance abuse treatment. Yet many successful combined-treatment programs have gotten around this problem by finding ways to supplement Medicaid.

Although the report addresses some obstacles that stand in the way of successful dual-diagnosis programs, it fails to address some deeper ones, Sheldon Miller, M.D., a dual-diagnosis authority at Northwestern University, believes.

"There is generally a structural disconnect between chemical dependency providers and mental health providers," Miller explained to Psychiatric News. "There is also immense stigma from one for the other—the chemical-dependency group stigmatizes mental health, and vice versa—and it includes both patients and providers. And are mental health professionals trained to care for the chemically dependent, and are the chemical-dependency [specialists] trained to care for the mentally ill? I think the answer is, probably not well. All of these things are critical issues. We need to talk about them."

The report, "Strategies for Developing Treatment Programs for People with Co-Occurring Substance Abuse and Mental Disorders," is posted on the Web at www.hccbh.org/cooccurringreport.pdf.

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