The Issue
     In any twelve-month period, an estimated 10 million people in this country will have a combination of at least one mental health and one substance abuse disorder. Three million individuals with co-occurring disorders have at least three disorders; one million have four or more.

     A report from the US Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that fifty-two percent of those with a lifetime history of alcohol abuse or dependence also had a lifetime mental disorder; 59% of those with a lifetime history of drug abuse or dependence had a lifetime mental disorder.

     The criminal justice system often becomes the "default" system of treatment for juveniles and adults with co-occurring substance abuse and mental health disorders. A literature review by the US Department of Justice’s Office of Juvenile Justice and Delinquency Prevention found that approximately 20% of youth involved in the juvenile justice system suffer from a serious mental disorder, and up to 80% of the juvenile justice population could be diagnosed with a conduct disorder. It is likely that the prevalence is even higher among the 1.8 million youth who enter the juvenile justice system each year. Data show that 73% of adult detainees with serious mental health disorders had a co-occurring substance abuse disorder.

The Barriers
     Individuals with co-occurring disorders are often told they must receive treatment from two separate providers or teams of providers. Unfortunately, individuals sometimes find themselves excluded from one or both systems because of complicating features of one or a combination of the disorders. Some mental health professionals are uncomfortable treating persons with co-occurring disorders, and instruct consumers to return for treatment only after completing treatment for the substance abuse disorder.

     In spite of consistent evidence regarding the needs of persons with co-occurring disorders to receive coordinated, comprehensive and integrated services, many stakeholders in the policy, prevention and treatment fields continue to remain divided on key issues. They debate about the use of already-tight financial resources for the treatment of persons with co-occurring disorders and about what constitutes effective treatment for persons experiencing co-occurring disorders. They further the arguments by continuing to underscore the differences in philosophy of treatment between the two fields. Even when they agree to collaborate, they meet resistance from providers who are trained in separate treatment models.

     Historical barriers to improving services to people with co-occurring disorders have included definitional problems (e.g., how to define "integrated treatment" or "co-occurring disorders"), lack of prevalence data, philosophical differences between the substance abuse and mental health fields, and concerns over adequacy of resources and/or the ability to access resources.

     While these barriers remain problematic in some areas, particularly the lack of resources, an atmosphere of collaboration is growing within the mental health and substance abuse fields as both fields recognize the critical need for effective treatment for co-occurring disorders, the multiplicity and complexity of problems experienced by people with co-occurring disorders, and the need to draw on the strengths of both fields in addressing these problems.

The Solutions
     There is no single set of treatment interventions that constitute integrated treatment for people with severe co-occurring addictive and mental disorders. Integrated treatment includes an array of appropriate substance abuse and mental health interventions identified in a single treatment plan based on individual needs and appropriate clinical standards and provided or coordinated by a single treatment team. Integrated treatment embodies several key principles in the delivery of services to people with co-occurring disorders. These principles include the following:

     Integrated services for people with co-occurring disorders should take a "no wrong door approach" to making services available and accessible no matter how or where an individual enters the system.

     Individuals should have access to a comprehensive array of services appropriate to their needs. Treatment for co-occurring disorders should be individualized to accommodate the specific needs of different subtypes and different phases of treatment for all established diagnoses. Recent scientific evidence suggests that assertive outreach and motivational interventions (i.e., to engage people in treatment and keep them in treatment) for substance abuse are necessary components of effective integrated treatment programs for individuals with co-occurring disorders.

     Services should be consumer-focused and family centered. Services providers should welcome individuals with co-occurring disorders and their families instead of rejecting them as unfamiliar or uncomfortable.

     Staff in settings providing integrated treatment should be fully oriented in each other’s disciplines. Individuals with co-occurring disorders should be able to receive services from primary providers and case managers who are cross-trained and able to provide integrated treatment themselves. 

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