The International Journal of Psychosocial Rehabilitation


SAMHSA / NASADAD
Release Report on Preliminary Information on Services to Individuals with Co-Existing Substance Abuse and Mental Health Disorders

July 17, 1998




Executive Summary

This monograph is a preliminary attempt to identify current issues that affect patients experiencing both a mental health and chemical dependency disorder, or "co-morbidity." The monograph draws information from State Alcohol and other Drug (AOD) Agencies and State Mental Health (MH) Authorities.

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) conducted a study of AOD Agencies and MH Authorities in fifty states and the District of Columbia. The purpose of the study was to determine how services to clients with co-occurring disorders are delivered, coordinated, funded, evaluated, and organized. Completed profiles were developed from internal data sources, then distributed to the AOD Agencies and MH Authorities in all fifty states and the District of Columbia. The information in a total of forty-one profiles was verified and returned to NASADAD from AOD Agencies (80% response rate) and twenty-seven from MH Authorities (53% response rate). The profile gathered and confirmed data in ten domains. These domains include:

1. Definition of co-occurring disorders.

2. Responsibility for provision of services to persons with co-occurring disorders.

3. Inter-organizational agreements for sharing resources for the provision of services to persons with co-occurring disorders.

4. Other systems involved in providing services.

5. Policies and regulations governing services provided to persons with co-occurring disorders.

6. Funds earmarked for the provision of services to persons with co- occurring disorders.

7. Management Information System capability to track persons with co-occurring disorders.

8. Monitoring effectiveness of treatment for co-occurring disorders.

9. Barriers that impede the provision of services to persons with co-occurring disorders.

10. Targeting of the provision of services to special populations with co-occurring disorders.

Summarized below are the reported responses in each domain from the State Directors of AOD Agencies and State MH Authorities.

Summary AOD and MH State Agency Information on
Services to Clients with Co-occurring Disorders

DOMAINS STATE AOD AGENCY AFFIRMATIVE RESPONSES STATE MENTAL HEALTH AUTHORITY AFFIRMATIVE RESPONSES
1. The agency/authority has a definition of co-occurring disorders (item A from State Profile). 73.2% 70.4%
2. There is assigned responsibility for provision of services to persons with co-occurring disorders (item B).  90% 85.2%
3. There are inter-organizational agreements or mechanisms for sharing resources necessary to provide services to clients with co-occurring disorders (item C). 56.1% 55.7%
4. There are other systems (e.g., criminal justice, housing) involved in providing substance abuse/mental health services to co-occurring disorder clients (item C.3). 53.6% 62.9%
5. The State Agency has policies and/or regulations which govern aspects of the services provided to co-occurring disorder clients, e.g., case management, assessment and referral, integration of treatment planning (item D). 56.1% 55.6%
6. The State Agency has funds that are exclusively earmarked for the provision of services to co-occurring disorder clients (item E). 51.2% 40.7%
7. The State Agency has the MIS capability to distinguish co-occurring disorder clients from other clients (item F). 75% 62.6%
8. Effectiveness of treatment for clients with co-occurring disorders is monitored (e.g., contracted study, provider reports, etc., item G). 41.5% 37%
9. There are barriers that impede the State from providing services to clients with co-occurring disorders (item H). 87.8% 81.5%
10. The State provides services targeting special populations with co-occurring disorders (item I). 51.22% 62.6%

A number of issues were highlighted by this preliminary study, which provides us with critical baseline information regarding co-occurring disorders. In response to some of the reported concerns by State Agencies/Authorities, recommendations are made to guide both AOD Agencies and MH Authorities to facilitate and coordinate their efforts to provide comprehensive services to a "co-morbid" population, thereby minimizing any fragmentation of services that may exist within the State system. .c.:A number of issues were highlighted by this preliminary study, which provides us with critical baseline information regarding co-occurring disorders. In response to some of the reported concerns by State Agencies/Authorities, recommendations are made to guide both AOD Agencies and MH Authorities to facilitate and coordinate their efforts to provide comprehensive services to a "co-morbid" population, thereby minimizing any fragmentation of services that may exist within the State system.

Summary of Recommendations:


Introduction: Genesis of the Task

The simultaneous occurrence of mental health and chemical dependency disorders, or "co-morbidity," has captured the interest of professionals from both the mental health and addictions fields for a number of decades. Within the last ten years, however, there has been a heightened sense of urgency attached to determining how best to address the problems presented by the dual diagnosis client. This increased interest has been fueled, in part, by studies that have provided us with a better understanding of the pervasiveness of the phenomenon. Concurrent with the research advancing our knowledge and scope of the dual diagnosis problem, another family of studies has been undertaken which shed more light on the causes and clinical nature of co-morbid disorders. Many studies have also examined the responsiveness of co-morbid disorders to differing types of treatment. An excellent review of the literature, contained in the Eighth Special Report on Alcohol and Health (NIAAA, 1993), was especially useful in the preparation of this report.

Interest in co-morbidity appears to have risen as our knowledge of the magnitude of the problem has become more sharply and realistically defined. Recent epidemiological estimates of the prevalence of co-morbidity are important in that those rates reflect actual or potential demand on both the Alcohol and Other Drug (AOD) treatment system and the Mental Health (MH) treatment system. An unknown but substantial portion of co-morbid clients are, or will become, clients of the public treatment systems administered by the State AOD Agency Directors and the State MH Authority Directors. The purpose of this study was to collect preliminary information needed to permit State Directors as well as Federal agencies to begin to develop a strategic plan which will allow the States to more effectively serve the nation's dual diagnosis population.

Recent epidemiological work in the area offers a picture of the extent of substance abuse and mental health disorders. Two are cited here to provide some context for the balance of the report. One of the first national surveys to shed light on the issue of co-morbidity, the Epidemiological Catchment Area Study (ECA), gathered data on institutionalized, non-institutionalized, and untreated individuals interviewed in household surveys, totaling approximately 21,000 persons between the ages of 18 and 65. The survey revealed that 23% of the participants had a lifetime history of mental disorder. Of those who reported a mental health disorder, 29% reported that they also had an alcohol or substance abuse disorder (Eaton, et al, 1989). A more current study, the National Co-morbidity Survey (NCS) found that 29% of all respondents reported a psychiatric disorder within the past 12 months (Kessler, 1994).

A number of studies have more specifically examined the prevalence of co-occurrence in the psychiatric population. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) at least 50% of the 1.5 to 2 million Americans with severe mental illness abuse illicit drugs or alcohol (Ridgeley, Osher, Talbot, 1987). This finding is reasonably consistent with earlier epidemiological studies which reported that between 25% and 50% of newly admitted psychiatric patients have concomitant drug and/or alcohol abuse problems (Davis, 1984; Kofoed, et al, 1986). No information is available to accurately estimate the degree to which such clients were receiving treatment for both disorders. Indeed, little quantitative information was found on the total number of co-morbid clients actually receiving services in either the public MH or AOD systems.

A rich body of anecdotal information, however, suggests that many individuals with co-occurring disorders participate in some form of treatment. Informal discussions with State Directors indicate that these clients are most frequently engaged in treatment approaches characterized by one of three conceptual frameworks. The first model might be described as serial treatment. In this model, discrete treatment programs address each disorder until it is under control, and then refer the client to another agency. The other disorder, or co-occurring disorder, is then treated until it is under control. Serial treatment has frequently led to clients being shuttled between agencies, sometimes without a long range or coherent treatment plan in place.

Another frequently used treatment model for those with co-occurring disorders is termed simultaneous or parallel treatment. In this model, two programs work together with the client at the same time, each treating one disorder. Theoretically, the programs exchange information about the nature and effectiveness of their treatment and about developments in the client's life. Experience shows, however, that even with the best of intentions, communications between programs is often poor. In addition, secondary issues may develop when one agency proposes activities or goals that contradict or are incompatible with the goals of the other agency.

An integrated treatment approach is the method receiving the most contemporary attention. Integrated treatment refers to the simultaneous treatment of all disorders by a dually trained clinician or a cross-trained treatment team whose members are competent to treat both the substance abuse and mental health disorders.

Fragmentation of behavioral health services at the State service delivery level may be the reflection of the influence of Federal legislation. A brief review of authorizing legislation that created the State MH and AOD delivery systems may help to explain present circumstances. Prior to 1963, the Federal Government was only minimally involved in Mental Health programming at the State and community level. Nor were significant Federal dollars committed to providing support for such services. At that time, there were few community based treatment facilities for the mentally ill. However, in 1963, President Kennedy requested that Congress authorize grants to the States to facilitate the creation of comprehensive community mental health centers. Made law the following year, the intent of the legislation was to treat the mental health patient in the community in which he or she resided through a comprehensive array of treatment services along with a range of ancillary services. The legislation also encouraged the establishment of State level planning and administrative oversight authorities.

The constellation of community-based mental health services that the legislation created also served as a model for those interested in providing similar services to alcoholics and the drug addicted.

Prior to 1970 the Federal Government did not have a substantive role in treating or preventing drug and alcohol problems other than operating narcotic treatment hospitals. In the late sixties, some money did become available to States and communities through criminal justice block grants to the States that were administered by the Law Enforcement Assistance Administration. It was not until 1970, however, that the Hughes Act (PL 91-616) was passed defining alcoholism as a treatable condition, establishing a National Institute on Alcohol Abuse and Alcoholism (NIAAA), and providing an Alcohol Formula Grant to each state to develop a planned treatment and prevention system. The following year saw the passage of PL 92-255, which created the National Institute on Drug Abuse (NIDA), and provided a Drug Formula Grant to each state. Both NIAAA and NIDA also made categorical grants directly to providers. These laws fundamentally changed the way States addressed substance abuse and financed community-based programs. According to the legislation, each State was required to designate units within State Government to serve as the State Alcohol Authority (SAA) and/or the Single State Agency (or SSA) for Drug Abuse. While many States created a single unit to act as both the SAA and SSA, equally as many created separate alcohol and drug agencies. Even in those cases in which combined agencies were established, alcohol and drug program financing were required to follow separate and often inconsistent rules and regulations. In essence, most States saw the development of separate mental health, alcohol, and drug treatment systems. While all states have now combined their alcohol and drug treatment systems, the State s MH systems remain, for the most part, separate entities. The States are now actively engaged in exploring the many possible options for ensuring that individuals in need of services from both systems receive those services in the most appropriate and effective manner.

In sum, the simultaneous occurrence of mental health and substance abuse disorders poses significant and potentially life-threatening problems for individuals, and multiple challenges for the alcohol, drug abuse, and mental health services fields. Urgent questions concerning the availability and economic impact of behavioral health treatment need to be answered so that scarce resources can be most effectively allocated. Separate service delivery systems, financing limitations, incompatible treatment philosophies, and inadequate training of providers, are systemic deficiencies that ultimately contribute to the problem of inadequately treated co-morbid disorders.


Objectives of the Task

In November 1995, SAMSHA hosted a national conference "Improving Services: Co-occurring Substance Abuse and Mental Health Disorders," to explore the existing level of knowledge around the area and to begin charting a course for future development. The outcomes of that initiative have been captured in a draft document titled Improving Treatment Services for Individuals with Co-occurring Substance Abuse and Mental Health Disorders (SAMHSA, 1996). This document identified a number of information needs and recommended the construction of a national database to better determine the epidemiology of the problem and capture specific and comprehensive data on treatment service delivery to these clients. It was also recognized, however, that before such a database could be constructed, considerable preliminary information was needed regarding existing conditions, especially at the State level. In 1996, the Center for Substance Abuse Treatment (CSAT) invited NASADAD to initiate work on the task.



 

METHODS

Project Plan

In October, 1996, NASADAD entered into a professional services contract with CSAT's Office of Scientific Analysis and Evaluation to provide CSAT with "current practices" foundation in service delivery to co-morbid populations among the States. NASADAD was to employ the use of an expert focus group to identify domains in which preliminary information was needed as a prerequisite to the development of a more comprehensive database on co-morbidity, and then collect information on those domains from the State AOD Agencies and MH Authorities.

Focus Group

The scope of the work agreed upon by NASADAD and CSAT called for: (1) the use of a focus group of expert researchers, administrators, and practitioners to review the purpose of the project; (2) the development of a list of State-level information domains relevant to the delivery of services to the dually diagnosed; and (3) the identification of the most appropriate sources of that information. The composition of the group was designed to elicit substantive content areas and data sources that would be accessible to NASADAD project researchers. The group included leading State AOD and Mental Health officials and providers (from Maryland and Virginia); key federal officials from SAMHSA, and other relevant agencies including alcohol, drug abuse, and mental health researchers with a demonstrated expertise in this area. Please refer to Appendix A for a complete list of focus group participants. On November 22, 1996, NASADAD convened that meeting at its headquarters in Washington, DC.

Focus Group Summary

The list of possible subject areas presented to the focus group for consideration included:

1. Mandates/polices establishing responsibilities for funding and/or services.

2. Organizational agreements/mechanisms for sharing resources or providing services.

3. Policies regarding AOD/MH patients, services, funding.

4. Funding amounts and sources.

5. Existing AOD/MH patient data.

6. Management Information Systems (MIS) patient tracking.

7. Program monitoring or evaluating treatment effectiveness.

8. Barriers to AOD/MH services.

9. Special population needs or other issues.

It was explained to the group that the purpose of the project was to compile general information of a descriptive and qualitative nature rather than empirically derived data.

Following the discussion, the members of the focus group agreed that the suggested information domains should be retained. In addition, the group felt that the following areas warranted consideration:

1. Provider licensure/accreditation requirements as they relate to the

facilitation or inhibition of services to co-morbid populations.

2. Assessment instruments currently in use, to include severity indices and patient placement criteria.

3. Consumer report cards/satisfaction surveys currently in use.

4. Definitions used in various state systems.

5. The need to include related systems, e.g., justice, housing, health care, vocational rehabilitation, etc., as possible sources of information about services to the dually diagnosed.

6. Practitioner's licensure/certification requirements as they relate to serving co-morbid clients.

Of the six additional domains suggested by the Focus Group Panel, two were ultimately retained for the study after being approved by the CSAT project officer: (4) definitions in use in various State systems, and (5) the need to include related systems, e.g., justice, housing, health care, vocational rehabilitation, etc., as possible sources of information about services to the dually diagnosed. The four remaining domains suggested by the panel were not included either because the information gained would be included in other domains or because they fell outside the scope of the project.The NASADAD project team and the CSAT project officer determined that the existing AOD/MH patient data domain could be subsumed under the MIS patient tracking domain, thus reducing the number of domains to be included in the study to 10. The 10 domains include:

1. Definition of co-occurring disorders.

2. Responsibility for provision of services to persons with co-occurring disorders.

3. Inter-organizational agreements for sharing resources for the provision of services to persons with co-occurring disorders.

4. Other systems involved in providing services.

5. Policies and regulations governing services provided to persons with co-occurring disorders.

6. Funds earmarked for the provision of services to persons with co-occurring disorders.

7. Management Information System capability to track persons with co-occurring disorders.

8. Monitoring effectiveness of treatment for co-occurring disorders.

9. Barriers that impede the provision of services to persons with co-occurring disorders.

10. Targeting of the provision of services to special populations with co-occurring disorders.

Data Collection Methodology

The original workplan structured by NASADAD project staff and CSAT initially involved the distribution of letters to State Mental Health and AOD Directors soliciting general information from each Director on the ten information domains.

This approach was pilot-tested with a small number of State Directors. Responses indicated that this approach to data collection would have been viewed by the NASADAD and National Association of State Mental Health Program Directors (NASMHPD) memberships as burdensome, and would result in the submission of material unsuitable for analyses. Feedback also indicated that such an information request would result in a very low response rate.

An alternate approach was therefore developed which utilized secondary data sources. Both NASADAD and NASMHPD have collected a significant amount of information from their members for other purposes, but which overlap with the requirements of this study. For all States, for example, NASADAD has basic information on the capabilities of the client level data systems that could contain data on the dual disorder patient population. This information was supplemented from various other sources such as Drug and Alcohol Services Information Systems (DASIS) Plans, which most States have submitted to SAMHSA's Office of Applied Studies and materials contained in summary reports of State AOD Agency Technical Reviews. NASMHPD has similar, rich data sources on the mental health reviews. After identifying information sources and extracting the relevant elements concerning the ten information domains for inclusion in draft State Profiles, NASADAD project staff made telephone calls to the State MH and AOD Directors to seek elaboration and/or clarification on any secondary source material that seemed ambiguous or vague. In sum, preliminary data sources included the NASADAD data base, the NASMHPD data base, the DASIS data base, and telephone contact with the directors of the state agencies/authorities. The information gathered in this manner was used to complete each item on the State Profile (see Appendix B). This provided NASADAD with a completed set of draft State profiles for each of the fifty states and the District of Columbia.

Following data collection, the completed draft profiles for each State AOD Agency and MH Authority were mailed to State officials in each of the fifty states and the District of Columbia for the purposes of verification, correction, and augmentation. Of the fifty states and the District of Columbia who received the draft profiles, forty one State AOD Agency Directors and twenty seven State MH Authorities returned the profiles with their comments, corrections, and verifications. This material provided the raw data for analysis in this study.



FINDINGS

This section of the report highlights the results from the verified and returned Draft State Profile of Services to Clients with Co-occurring Disorders (a copy of the profile is included in the Appendix). The profile ncluded data in ten information domains. Since forty one responses were received from AOD Agencies and twenty seven from MH Authorities, response rates were 80.4% for AOD Agencies and 53% for MH Authorities, when N=51.

For the findings in each domain, a table with data corresponding to the reported results from both AOD Agencies and MH Authorities is included along with a brief narrative. Each domain refers to a specific item on the state profile. That item is cited in the table description.

Quantitative analyses were limited to frequency counts and associated percentages. The percentages reported in this section are based on the number of State AOD Agencies (N=41) and MH Authorities (N=27) that responded to NASADAD's request for information. Although it is tempting to compare rates of agreement between the two types of services regarding the various domains, it is important to keep in mind that the response rate from MH Authorities was considerably lower than the response rate for AOD Agencies (1:1.5). Any comparison of rates of agreement between the two types of services would be misleading.

When examining these findings, please refer to Appendix B for a copy of the Draft State Profile instrument used in the study.

Domain 1: The State agency has a definition of co-occurring disorders.

The majority of the responding State AOD Agencies (N=41) and State (MH)Authorities (N=27) reported having a formal or informal definition of co-occurring disorders. Table 1 below describes the responses to item A of the State Profile (Appendix B). Specifically, almost three-quarters (73.2%) of the State AOD Agencies and (70.4%) State MH Authorities reported having a working definition of co-occurring disorders.

Table 1

1. Percentage of State AOD Agencies and MH Authorities with a definition of Co-occurring Disorders AOD Agency Affirmative Responses MH Authority Affirmative Responses
  73.2% 70.4%
Slightly more than one-third (34.6%) of the State AOD Agencies and almost half (47.45%) of the State MH Authorities use diagnostic criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), in part or in whole, in their definition of co-occurring disorders. (See Appendix C for examples of State AOD Agency and MH Authority definitions of co-occurring disorder clients). These definitions range from the succinct such as "a diagnosis of both mental illness and substance abuse" to a 9-level definition that reflects the severity of either the substance abuse or mental health disorder presented by the client. Some state definitions of co-occurrence specifically include clients with severe and/or disabling mental health disorders. For example, one State AOD Agency reported its definition of co-occurring disorders as "substance abusers with personality disorders, severe and persistent mental illness, and mood disorders, each having outcome measures to be determined by each population." Other definitions make no reference to severity. For example, One State AOD Agency reports its definition of co-occurring disorder as "a concomitant psychiatric disorder and substance abuse disorder."

State MH Authorities definitions of co-occurring disorders also range from succinct to elaborate, complex definitions. For example, a few State MH Authorities reported their definitions of co-occurring disorders as simply "a diagnosis of both types of disorders." Another State MH Authority reported their definitions of co-occurring disorders as "an individual with a diagnosis of schizophrenia, schizo-affective disorder, delusional disorder, paranoid personality disorder, schizotypal personality disorder, borderline personality disorder, bi-polar disorder, or major depression and a diagnosis of psychoactive substance abuse or dependence." It is interesting to note that, in some cases, State AOD Agencies and State MH Authorities do not share the same definition of co-occurring disorder. However, in cases where both the AOD Agency and MH Authority are part of the same parent agency, they are more likely to use a common definition of co-occurring disorder.

Domain 2: Assigned responsibility for provision of services to persons with co-occurring disorders.

Data were collected regarding item B in the State profile the "assignment of responsibility for the provision of services to persons with co-occurring disorders." 90.0% of the State AOD Agencies (N=41) and 85.2% of State MH Authorities (N=27) reported that, within the context of their respective State government, a State agency or agencies had been assigned that responsibility

Table 2

2. Percentage of State AOD Agencies and MH Authorities reporting that the responsibility for serving the needs of the persons with co-occurring disorders had been assigned to a State agency/agencies AOD Agencies Affirmative Responses MH Authorities Affirmative Responses
  90.0% 85.2%

Detail Regarding the Agency/Authority with Assigned Responsibility

State Agency/Agencies assigned responsibility for the provision of services to persons with co-occurring mental health and substance abuse disorders AOD Agencies  MH Authorities 
Both the AOD and MH Authorities 58.8% 60.8%
A Parent State Agency that Includes the AOD and MH 35.3% 30.4%
State MH Agencies 5.9% 8.7%
State AOD Agencies 0.00% 0.00%
A State Agency Other Than Those Listed Above 0.00% 0.00%
The modal response to this item from AOD Agencies and MH Authorities was "shared responsibility" by both of those organizations. More than one-half (58.8%)of the State AOD Agencies and two-thirds (60.8%) of the State MH Authorities reported that the responsibility for the provision of services to persons with co-occurring disorders is assigned jointly to the State AOD Agencies and MH Authorities. More than one-third (35.3%) of the State AOD Agencies and 30.4% of the State MH Authorities reported that the responsibility had been assigned to a parent State Agency that includes the State AOD Agency and the State MH Authority. A few (5.9%) of the State AOD Agencies and 8.7% of the State MH Authorities indicated that the responsibility to provide services to co-occurring disorders was assigned to the State MH Authority. None of the State AOD Agencies or State MH Authorities reported that the responsibility had been assigned exclusively to the AOD Agency, or an agency of the type not previously identified in this analysis.

Domain 2a: If the responsibility to provide services to persons with co-occurring disorders has been assigned, the source of the authority for the assignment of this responsibility is:

With respect to item B of the State Profile the "source of authority for the assignment of responsibility", Table 2a lists the responses for both AOD Agencies (N=41) and MH Authorities (N=27).

Table 2a.

2a. The source of authority for the assignment of responsibility to serve co-occurring disorder clients is: AOD Agency Responses MH Authority Responses
Agency Policy 33% 52.2%
Informal Agreement 24% 13.4%
Legislation 24% 30.4%
Other 21% 4.4%
More than half (52.2%) of the State MH Authorities and approximately one-third (33%) of the State AOD Agencies reported that an agency policy was the source of authority that assigned responsibility to provide services to clients with co-occurring disorders. Approximately one-quarter (24%) of the State AOD Agencies and a smaller number (13.4%) of the State MH Authorities reported that an informal agreement was the source of authority for the assignment of responsibility. Approximately one-quarter (24%) of the State AOD Agencies and one third (30.4%) of the State MH Authorities reported that legislation was the source of authority. Another one-fifth (21%) of the State AOD Agencies and a few (4.4%) of the State MH Authorities reported that neither an agency policy, an informal agreement, nor legislation was the source of authority for which the responsibility emanated. Those agencies identified "other" issues as the determinate source of responsibility, e.g., the nature of presenting problems, primary diagnosis, and licensing regulations. Additionally, 86% of State AOD Agencies and 78.3% of State MH Authorities indicated that assigned responsibility to provide services to clients with co-occurring disorders included responsibility to pay for services provided to publicly funded clients

Domain 3 There are inter-organizational agreements for sharing resources for the provision of services to persons with co-occurring disorders:

The responses to item C on the State Profile (Appendix B) revealed that more than one-half (56.1%) of the State AOD Agencies and more than one-half (55.7%) of the State MH Authorities reported having "inter-organizational agreements for sharing resources necessary to provide services to clients with co-occurring disorders." Table 3 lists the results from AOD Agencies (N=41) and MH Authorities (N=27) responding to this item.

Table 3

3. There are inter-organizational agreements for sharing resources necessary to provide services to clients with co-occurring disorders  AOD Agency Affirmative Responses MH Authority Affirmative Responses
  56.1% 55.7%
Among both AOD Agencies and MH Authorities, the inter-organizational agreements include memoranda of understanding, a dual diagnosis task-force, and provider network agreements. Two States reported that both AOD and MH is administered by the same agency, therefore, no such agreement is necessary. However, the majority of the reported responses indicated that there is either a formal or informal agreement that allows for sharing of resources to provide services to persons with co-occurring disorders. Other State AOD Agencies and State MH Authorities indicated that although there are memorandas of understanding and/or dual diagnosis task forces, many of the inter-organizational agreements are being formalized in an effort to provide a continuum of care for dual diagnosed clients. See Appendix D for examples of the types of inter-organizational agreements AOD Agencies and MH Authorities described.

Domain 4: There are other systems (e.g., criminal justice, housing) involved in providing substance abuse/mental health services to clients with co-occurring disorders.

More than half (53.6%) of the State AOD Agencies (N=41) and two-thirds (62.9%) of the State MH Authorities (N=27) indicated that there are other systems involved in providing services to clients with co-occurring disorders. Table 4 below lists the results of item C.2 from the State Profile.

Table 4

4. State entities participate in agreements or mechanisms for sharing resources necessary to provide services to clients with co-occurring disorders AOD Agency Affirmative Responses MH Authority Affirmative Responses
  53.6% 62.9%

Detail Regarding Agreements/Mechanisms for Sharing Resources:

Mental Health Authorities with AOD Agencies   100%
Alcohol and Other Drug Abuse Agencies with MH Authorities 95.65%  
Judiciary/Corrections/Probation/Parole 13.4% 20%
Social Service 26.9% 20%
Other 17.4% 13.3%
Nearly all (95.6%) of the State AOD Agencies that reported having an arrangement with their respective State MH Authority to share resources in the provision of services to dual diagnosis (53.6%) stated they had such an arrangement with the MH Authority. All (100%) of the State MH Authorities that reported agreements with other agencies (62.9%) reported working with the State AOD Agency. Additional agency agreements cited by both the State AOD Agencies and the State Mental Health Authorties include Judiciary / Correction / Probation agencies (13.4% and 20% respectively, State Social Service agencies (26.9% and 20% respectively,) and other State Agencies (17.4% and 13.3%, respectively). Those agencies in other institutions or systems indicated by AOD Agencies and MH Authorities involved in providing services to clients with co-occurring disorders included medical schools, departments of Economic Security, Housing, and Community Affairs, as well as acute and long-term care programs, and programs for the developmentally disabled.

Domain 5: The agency has policies and regulations which govern aspects of the services provided to clients with co-occurring disorders (e.g. case management, assessment and referral, integration of treatment planning)

More than half (56.1%) of the State AOD Agencies (N=41) and more than half (55.6%) of the State MH Authorities (N=27) have policies and/or regulations that govern aspects of the services provided to clients with co-occurring disorders.

Table 5

5. AOD Agencies and MH Authorities with policies and/or regulations that govern aspects of the services provided to clients with co-occurring disorders  AOD Agency Affirmative Responses MH Authority Affirmative Responses
  56.1% 55.6%

Table 5 describes the responses to item D from the State Profile. Refer to Appendix E for specfic examples of responses to item D from the State Profile.Some of the instruments governing services include memorandums of understanding, informal agreements, dual diagnosis task forces, a dual diagnosis coordinator, and a multi-disciplinary team. For example, a State reported that it had a "task force working to develop policies that recognize co-occurring disorders, to rewrite standards to assess dual diagnosis, and to change rules/policies to treat this population." Another State reported that "the recent integration of the mental health and substance abuse at the State Agency level will lead to better coordination of the services for individuals with co-occurring disorders." Mental health and substance abuse professionals serve together on a team to plan delivery of services under a managed care model." For both AOD Agencies and MH Authorities, some of the other policies, practices, and functions include conferences and workshops about co-occurring disorders, and trainings that sometimes pertain to substance abuse and mental health, and other times are specific to dual diagnosis.

MH Authorities also reported having subgroups comprised of AOD and MH personnel to plan and address co-occurring issues. Overall, both AOD Agencies and MH Authorities frequently reported utilizing task forces and cross training of staff as practices that support the delivery of treatment services to clients with co-occurring disorders.

Domain 6: The organization has funds earmarked exclusively for the provision of services to persons with co-occurring disorders.

More than half (51.2%) of the State AOD Agencies and 40.7% of the State MH Authorities reported that they have funds that are earmarked exclusively for the provision of services to clients with co-occurring disorders. Responses to item E in the State Profile are described in Table 6

Table 6

6. Funds earmarked exclusively for the provision of services to clients with co-occurring disorders AOD Agency Affirmative Responses MH Agency Affirmative Responses
  51.2% 40.7%
The source of these funds varies from State allocated funds to Federal Block Grants. The range of funding reported by the State AOD Agencies was between $100,000 and approximately $5 million. The range reported by the State MH Authorities was between $372,000 and $3.9 million

Domain 7: The organization has the Management Information Systems (MIS) capability to distinguish between clients with co-occurring disorders and other clients

Information was reported on several aspects of state MIS capabilities to identify, describe, track, and monitor clients with co-occurring disorders by both AOD Agencies (N=41) and MH Authorities (N=27). Responses to item F in the State Profile are listed in Table 7.

Table 7

7. The State Agency/Authority has the MIS capability to distinguish between co-occurring disorder clients from other clients State AOD Agency Affirmative Response State MH Authority Affirmative Response 
  78% 62.6%
More than three- quarters (78%) of the AOD Agencies and almost two-thirds (62.6%) of the MH Authorities reported having the MIS capability to distinguish between clients with co-occurring disorders and other clients. Over eighty percent (82.7%) of State AOD Agencies and three-quarters (76.5%) of the State MH Authorities use a "unique" client identifier to help identify and distinguish each client. About half (49.4%) of the State AOD Agencies. Over one-third (39.6%) of the State MH Authorities reported using a "synthetic" client identifier (e.g., last four characters of mother's maiden name, date of birth, or county code). Less than one-third (30.3%) of the State AOD Agencies and approximately one-half (47.6%) of the State MH Authorities reported using an "actual" client identifier (e.g., social security number).

Among the State AOD Agencies that have the ability to distinguish dual-diagnosed clients from other clients, almost two-thirds (63.7%) can track co-occurring disorder clients within and between substance abuse facilities, and one-quarter (25.4%) can track co-occurring disorder clients within mental health facilities. Similarly, of the State MH Authorities with the MIS capability to distinguish co-occurring disorder clients from other clients, more than two-thirds (66.4%) can track co-occurring disorder clients within and between substance abuse facilities, and 82.5% can track co-occurring disorder clients within and between mental health facilities.

Domain 7a: The States have the MIS capability to include discharge data on clients identified as having a co-occurring disorder.

Table 7a

7a. The MIS on co-occurring disorder clients includes discharge data State AOD Agency Affirmative Responses State MH Authority Affirmative Responses
  81.3% 87.5%
Of the Agencies/Authorities who have the MIS capability to track clients with co-occurring disorders within the general population of clients, 81.3% of the AOD State Agencies, and 87.5% of the State MH Authorities say this tracking includes data related to the client's discharge from treatment. Please refer to Chart 1 on the following page, which depicts graphically the Client Characteristics found in AOD Agency and MH Authority Management Information Systems.

Domain 8: Effectiveness of treatment for clients with co-occurring disorders is monitored/evaluated (e.g., contracted, study, provider reports, etc.)

41.5% State AOD Agencies (N=41) and the 37% State MH Authorities (N=27) monitor the effectiveness of the treatment for co-occurring disorders. Responses to item G in the State Profile are listed in Table 8

Table 8

State AOD and MH Authorities reporting that treatment effectiveness is monitored. AOD Agency Affirmative Responses MH Authority Affirmative Responses
  41.5% 37.0%
The monitoring and/or evaluation methods used by each agency vary. For example, one State AOD Agency uses data set matching. Another State AOD Agency uses follow-up studies and admission-to-discharge data. Other AOD Agencies monitor clients with co-occurring disorders by utilizing quality assurance teams comprised of substance abuse and mental health professionals who make site visits, review cases and interview clients on a regular basis. One State, however, indicated that the AOD Agencies and MH Authorities are in the process of developing mechanisms that will utilize standardized assessment results and outcome measures to determine appropriateness/effectiveness of treatment. Some of the State MH Authorities use other methods of monitoring the effectiveness of treatment for clients with co-occurring disorders including: (1) outcome measures at client and state levels; (2) the use of outcome data sets; and (3) treatment accountability plans. See Appendix F for examples of the methods used by the State AOD Agencies and State MH Authorities to monitor effectiveness of treatment for co-occurring disorder clients.

Domain 9: There are barriers that impede the State from providing services to persons with co-occurring disorders (e.g., State AOD provider standards do not permit the direct treatment of the mental health conditions by AOD staff, practitioner standards (AOD) do not extend to MH services, except for those holding dual certification/licensure, lack of cross-training, etc.).

More than four-fifths (87.8%) of the State AOD Agencies (N=41) and more than four-fifths (81.5%) of the State MH Authorities (N=27) reported barriers that impede the State from providing services to clients with co-occurring disorders. Responses to item H from the State Profile are listed in Table 9.

Table 9

State AOD Agencies and MH Authorities reporting service barriers AOD Agency Affirmative Responses MH Authority Affirmative Responses
  87.8% 81.5%
The barriers most frequently reported by the States fall into one of four inter-related categories: need for additional funding, need for additional, appropriate resources, need for appropriate provider training/certification, and need for enhanced co-ordination of services.

The need for additional funding was the most frequently reported barrier. States reported that additional funding would allow opportunities to apply funds to the specific needs identified by each State. States frequently indicated the need for additional resources including housing assistance, appropriate facilities, and staff in rural and other hard-to-reach areas. Other key barriers cited included the need for appropriate training, education, and certification of the treatment staff. Many staff members reported the need for improved coordination between the State AOD Agencies and the MH Authorities. Specifically, the States noted the need for development of joint policies, understandings, and working within a mutual, professional culture, and the need to end "turf battles." States also reported philosophical differences between substance abuse and mental health staff concerning appropriate treatment and desired outcomes (e.g., abstinence versus harm reduction, and the use of psychotropic medications with alcoholics and addicts). It is important to note that in most States, except for those staff holding dual certification or licenses, AOD staff cannot make mental health diagnoses or provide mental health treatment, due to certification/licensure limitations. Conversely, mental health staff holding MH certification and/or licensure can make AOD diagnosis and can prescribe a necessary course of treatment. See Appendix G for examples of the barriers identified by the State AOD Agencies and State MH Authorities.

Domain 9a: Policies, practices, or functions that support the provision of services to persons with co-occurring disorders.

The majority of the State AOD Agencies (82.9%) and the State MH Authorities (85.2%) reported the use of policies, practices, or functions that support the delivery of services to clients with co-occurring disorders. Table 9a describes the responses to item H.2 in the State Profile.

Table 9a

9a. Policies, practices or functions that support the provision of services to persons with co-occurring disorders. AOD Agency Positive Responses MH Authority Positive Responses
  82.9% 85.2%
The most common policy and/or practices that support the provision of services to persons with co-occurring disorders reported by both State AOD Agencies and MH Authorities were: (1) cross-training of staff; (2) task force groups; and (3) co-location of AOD and MH staff. Other policies and practices include the development of State pilot programs, and staff comprised of AOD and MH personnel to jointly develop service delivery plans. Additionally, a few State AOD Agencies reported that hosting conferences and workshops regarding co-occurring disorders would bridge existing gaps between AOD and MH professionals.

Domain 10: The State provides services targeting special populations with co-occurring disorders (e.g., HIV/AIDS, homelessness).

Just over one-half (51.2%) of the State AOD Agencies and almost two-thirds (62.6%) of the State MH Authorities reported providing services targeting special populations with co-occurring disorders. Table 10 describes the responses to item I in the State Profile.

Table 10

10. State reporting services targeting special populations with co-occurring disorders AOD Agency Positive Responses MH Authority Positive Responses
  51.22% 62.6%
These special populations include the homeless, clients diagnosed with HIV/AIDS, women with children, pregnant women, persons with severe and persistent mental illness, older persons, emotionally disturbed children, and those in the criminal justice system. Many states reported that although they do not target special populations with co-occurring disorders, the States do provide services to all clients including those with co-occurring disorders. See Appendix H for examples of special populations served by State AOD Agencies and State MH Authorities.


DISCUSSION AND IMPLICATIONS

This section of the report on NASADAD's work with State AOD Agencies and State MH Authorities to determine some of their activities, policies, data, and services related to persons with co-occurring disorders is organized into the following three subsections:

- Strengths and Limitations of the Data/Results;

- Implications of Findings from Each of Ten Major Information Domains; and

- Recommendations for the Future.

Strengths and Limitations of the Data/Results

The data presented and analyzed within this report were collected based on secondary data accessed by NASADAD, NASMHPD, DASIS, and information provided by telephone and in writing by Directors and/or staff within the State AOD Agencies and the State MH Authorities. All of the separate State AOD Agencies (N=51) and MH Authorities (N=51) were given the opportunity to verify and augment data extracted and collated from various State reports that were available to and reviewed by NASADAD staff. Only those State AOD and MH Authorities who returned the draft profiles with their comments and verifications were included in the study. Over four-fifths (80.4%) of the State AOD Agencies (N=41) and over half (53%) of the State MH Authorities (N=27) responded to this request from NASADAD to verify, augment, or correct information provided to the State Agency/Authority on the draft State Profile. Please refer to Appendix I for a listing of the responding states by AOD Agency and MH Authority

One significant limitation to the study concerns the identification of the respondents by their state name. Most states require an additional, in-state review process of any study or survey that would identify and rank respondents by state name. The time-frame for this study could not accommodate this review process, which in some cases may take months. Therefore, the anonymity of the respondents was respected so that the study could be completed within the period of time allowed.

The difference in response rates (1:1.5) between State MH Authorities (53% when N=51) and State AOD Agencies (80.4% when N=51) may be explained by the fact that the nformation was solicited by NASADAD. All State AOD Agencies work closely with NASADAD on an ongoing basis and are members of NASADAD. Therefore, they may be favorably predisposed to respond to information requests from NASADAD. Many of the State MH Authorities have limited working knowledge of NASADAD. Thus, despite efforts by the Executive Director of NASMHPD who encouraged State MH Authorities to respond, as well as follow-up requests made by NASADAD staff, the overall response rate from State MH Authorities was much lower than the response for State AOD Agencies.

Since a response rate of 80.4% was achieved for data from the State AOD Agencies, the information collected, analyzed, and presented in this report is generally representative of State AOD Agencies. However, due to the lower response rate for State MH Authorities, it cannot be said that the data is generally representative of State Mental Health Authorities. In addition, the different response rates between the AOD Agencies and the MH Authorities prohibits a meaningful comparison of rates of agreement. For example, in Table 1, it would seem that one could conclude that the same number of State AOD Agencies and the same number of State MH Authorities have a definition for co-occurring disorders. That would be an erroneous conclusion, since the MH Authority response percentage is based on N=27, and the AOD response percentage is based on N=41. In fact, 29 of the AOD Agencies and 19 of the State MH Authorities (who responded) have definitions of co-occurring disorders.

In some ways NASADAD's success in obtaining data from 80.4% of the State AOD Agencies, but only 53% of the State MH Authorities, mirrors some of the difficulties in asking separate Federal, State, or local AOD Agencies and MH Authorities and practitioners to effectively cooperate in providing services to persons with co-occurring disorders. In general, there exists good will between AOD Agencies and MH Authorities, along with a desire to place the needs of the treatment client as primary. However, on a practical day-to-day basis, other priorities may interfere or otherwise prevent the delivery of the most effectively coordinated or integrated services for the client with a co-occurring disorder.

Implications of Findings from Each of Ten Information Domains

This subsection presents and discusses some of the more important implications from the findings on each of the ten information domains considered in this study.

Domain 1: The State agency has a definition of co-occurring disorders.

About 70% of State AOD Agencies(N=41) and 70% of State MH Authority respondents (N=27) have some type of definition in place for co-occurring disorders. However, our findings indicate wide variation in the definition of co-occurring disorders across the states included in this study (see Appendix C). Also, it appears that only clients with severe and/or disabling substance abuse and mental health disorders are included within most of the State definitions of co-occurring disorders. This finding suggests that for those persons with less than severe forms of co-morbidity, access to necessary services may be limited. Clearly, the delivery of services to persons with mild, moderate, or less than severe co-occurring disorders is important to consider given that early detection, prevention and treatment of co-morbid disorders is more cost-effective than treating severe co-morbid disorders.

Many of the definitions of co-occurring disorders appear to be informal working definitions rather than legislatively determined ones. This indicates the likelihood of openness and flexibility on definition issues. Prior to further legislative determination of definitions of co-occurring disorders at the State level, it may be advisable for SAMHSA to plan and convene one or more national or regional conferences to bring together State AOD Agency and MH Authority representatives and other experts. This conference would be a forum to discuss these critical issues and to attempt to reach some consensus on appropriate definitions, including consideration of the different forms of co-morbidity and the issue of the range of severity. Such consensus on definitions of co-occurring disorders could potentially stimulate state attention to these issues and facilitate interagency cooperation and coordination in the planning and delivery of the most effective services to this often neglected client population.

Another less costly approach might be for SAMHSA to develop some alternative draft definitions of co-occurring disorders and ask State AOD Agency and MH Authority representatives to provide their thoughts and feedback on the draft definitions.

This approach, though potentially less effective than the conference mechanism, might stimulate some State Agency/Authority involvement on these issues, in establishing more cooperative exchanges directly between State Agency representatives on service delivery issues within their own States.

Domain 2: Assigned responsibility for provision of services to persons with co-occurring disorders.

and

Domain 2a: If the responsibility to provide services to persons with co-occurring disorders has been assigned, the source of the authority for the assignment of this responsibility is:

Approximately 85% to 90% of State Agency respondents reported that one or more specific State Agencies had "been designated as responsible for the provision of services to persons with co-occurring disorders." This finding is quite positive in terms of indicating that States are actively involved, not only in paying attention to, but also assigning specific service responsibility for these areas. An important related finding is that within those States where responsibility for the provision of services has been specifically assigned to one or more State Agencies, the most common assignment (58.8% of State AOD Agencies and 60.8% of State MH Authority respondents) is to both the State AOD Agency and MH Authorities. The next most common assignment is to "a parent State Agencythat includes both the AOD and MH Authorities" (by 35.3% of State AOD Agencies and 30.4% of State MH Authority respondents).

The finding of shared responsibility for co-occurring disorders by both the State AOD Agency and the State MH Authorities is not unexpected. However, it reinforces the reality and need to bring together representatives from these two systems to directly discuss these critical issues. Some of the potential benefits of shared responsibility are that the real treatment and service delivery expertise of both agencies can be brought to bear to resolve problems and to more effectively and efficiently provide necessary services to the client. Also, within the State bureaucracy, these two agencies working together can generally garner more support and resources for jointly agreed upon priorities than either agency working alone. It would be important, however, to create safeguards against the diffusion of responsibility that such a partnership might engender.

Another important finding is that the "source of authority for the assignment of responsibility" is most often either "agency policy" (33% AOD to 52.2% MH respondents) or an "informal agreement" (24% to 13.4%), rather than being "legislation" (24% to 30.4%). This finding implies that most of the State Agencies/Authorities currently have flexibility to refine and improve conditions and services without necessarily having to go through the often difficult and lengthy process of changing legislation.

Domain 3: There are inter-organizational agreements for sharing resources for the provision of services to persons with co-occurring disorders:

56.1% of State Agency respondents and 55.7% of the State MH Authority respondents indicated that inter-organizational agreements or other mechanisms (e.g., task forces, jointly funded staff and/or pilot programs, multidisciplinary teams, and referral agreements) are currently in place to share resources to provide services to clients with co-occurring disorders.

From the findings reported above, it appears that most States already have inter-organizational agreements in place to share resources in providing services to persons with co-occurring disorders. An important next step might be to assess the effectiveness of the various approaches. State Agencies that appear to have the most effective models in place could be asked to share their experiences and expertise with other States, particularly with those 40% that currently lack such inter-organizational agreements or other relevant mechanisms designed to provide improved services for persons with co-occurring disorders. Sharing of this information among State Agencies could occur through a variety of mechanisms ranging from conferences, to technical assistance manuals, to on-site staff training and technical assistance.

Domain 4: There are other systems (e.g., criminal justice, housing) involved in providing substance abuse/mental health services to clients with co-occurring disorders.

In addition to the State AOD Agencies and the State MH Authorities, other frequent organizational partners in agency agreements include Social Services (identified by 26.9% of the State AOD Agencies and 20% of the State MH Authority respondents) and Judiciary / Corrections / Probation /Parole (identified by 13.4% of the State AOD Agencies and 20% of the State MH Authority respondents). Other partners in these agreements range from Departments of Community Affairs, Economic Security, and Housing, to medical schools and universities. Given the complexity and broad range of psycho-social issues often seen in the co-morbid population, it is encouraging to find that over half of all states in this study include other systems in the provision of services to persons with co-occurring disorders. Although precluded by the limited scope of the present study, a more thorough examination of these multi-system relationships may yield important information concerning the organization, financing, and delivery of services for the co-morbid population. Sharing such information across the states via conferences, technical assistance programs, and on-site training and assistance could focus on model or exemplary multi-system relationships, methods to reduce barriers to cross system collaboration, as well as mechanisms for assessing the effectiveness of such collaborations.

Domain 5: The agency has policies and regulations which govern aspects of the services provided to clients with co-occurring disorders (e.g. case management, assessment and referral, integration of treatment planning).

Over half of the State AOD Agencies (56.1%) and State MH Authority respondents (55.6%) have policies and/or regulations in place that govern services provided to persons with co-occurring disorders. These range from best practice standards to statements of principles, from State licensure and requirements for case management to Commission on Accreditation of Rehabilitation Facilities (CARF) Accreditation, and from Medicaid service requirements to memoranda of understanding.

The tremendous diversity of policies and regulations in this area could be a rich and fruitful basis for discussion among State Agency/Authority representatives and other content area experts. Whether such variations are appropriate given the current lack of extensive science based knowledge on treatment effectiveness in this area, or whether recent advances warrant the establishment of more specific requirements and regulations for programs and practitioners that deliver services to persons with co-occurring disorders could be the focus for that discussion.

Domain 6: The organization has funds earmarked exclusively for the provision of services to persons with co-occurring disorders.

Along with an assigned responsibility to provide services to persons with co-occurring disorders, approximately four-fifths of the State Agencies (86% of the State AOD Agencies and 78.3% of the State MH Authority respondents) have the responsibility to pay for such services when they are provided to publicly funded clients.

It is one thing to have a broad general policy to offer or provide certain types of services. However, it is much more serious and significant when the policy includes the responsibility for actual fiscal payment or reimbursement for these services when they are provided to public clients. The latter is the case with regard to services for co-occurring disorders for about four-fifths of the State Agencies.

Domain 7: The organization has the Management Information Systems (MIS) capability to distinguish between clients with co-occurring disorders and other clients

and

Domain 7a: The States have the MIS capability to include discharge data on clients identified as having a co-occurring disorder.

A large proportion of both State AOD Agencies (75%) and State MH Authority respondents (62.6%) reported that their MIS can identify and differentiate between clients who do and do not have co-occurring disorders, primarily through the use of unique client identifiers. Also, most States with such MIS capabilities report that clients with co-occurring disorders can usually be tracked from one facility to another (except that most State AOD Agencies can track clients within the AOD system, but not within the MH or other State systems). In addition, over four-fifths of State Agencies with MIS capabilities report that they capture both client admissions data and client discharge data.

It is important to collect more extensive and detailed information on specific State Agency MIS operations and capabilities both overall and specifically with regard to clients with co-occurring disorders. Also, it is important to determine the degree to which data elements across states have identical or similar definitions and can be reasonably compared. NASADAD's prior experience with State MIS and other data systems indicates that although many State data systems provide valid and reliable data for those individual States, the systems are often idiosyncratic and tailored to meet unique State needs. It is most difficult to collect individual client data that can be compared across States.

In addition, many State Agencies have accurate and valuable aggregate data, but begin to experience difficulty in tracking individual clients and services over time and across different facilities. In this respect, States may have overstated their client-tracking capabilities.

The lack of comparable data and systems across States is not unexpected given that the systems were usually designed, developed, and operated by individual States to meet their own needs. The Federal government has generally provided minimal fiscal resources to the States to support the design and operation of service-oriented AOD/MH data systems. Instead, the Federal government has recognized that States have unique data needs. At the same time, the lack of an integrated national data system has resulted in a number of problems since directly comparable information across States on clients with co-occurring disorders is generally not available. The ongoing issue of State-generated, client level data systems vs. an integrated, national data system deserves more sustained and intensive attention, discussion, and resources from both Federal and State representatives.

Domain 8: Effectiveness of treatment for clients with co-occurring disorders is monitored/evaluated (e.g., contracted, study, provider reports, etc.)

Approximately 40% of State Agencies (41.5% of AOD and 37% of MH Authority respondents) reported that they monitor the effectiveness of treatment for persons with co-occurring disorders. Monitoring methods vary. They may consist of analyses of admission and discharge data, consumer satisfaction surveys, quality assurance team reviews, client follow-up studies, or special research studies. A research study may involve pre/post comparisons of client utilization and costs within the health and criminal justice systems for persons who have received treatment services for co-occurring disorders.

The range of monitoring and evaluation methods utilized by selected States to determine the effectiveness of treatment services for persons with co-occurring disorders is impressive in terms of its broad scope and apparent scientific rigor and sophistication. The finding that most States have not implemented monitoring, evaluation, and research components in their treatment services for persons with co-occurring disorders points to the need for national leadership and resources from agencies such as SAMHSA, CSAT, NIAAA, NIDA, NIMH.

One cost-effective method to respond to this identified evaluation research need might be to present the current efforts of several different States that are already active in these areas as models for other State representatives who may be interested in initiating their own evaluations. Such presentations should be followed up with the provision of on-site technical assistance from State and other evaluation experts, as well as the provision of some Federal research and/or knowledge development monies to support State level research in these critical areas.

Domain 9: There are barriers that impede the State from providing services to persons with co-occurring disorders (e.g., State AOD provider standards do not permit the direct treatment of the mental health conditions by AOD staff, practitioner standards (AOD) do not extend to MH services, except for those holding dual certification/licensure, lack of cross-training, etc.)

and

Domain 9a: Policies, practices, or functions that support the provision of services to persons with co-occurring disorders.

Over four-fifths of the State Agencies (87.8% of the AOD Agencies and 81.5% ofthe MH Authority respondents) reported that barriers exist that impede their delivery of services to persons with co-occurring disorders. The barrier reported most frequently was the need for additional funding to serve this particular population.

Although this finding is not unanticipated, it reinforces the obvious difficulty faced by most State Agencies when they wish to provide increased or enhanced services to any one population, such as persons with co-occurring disorders. If new monies are not identified for this particular population by the Federal, State, or other levels of government, then services to some other currently served population must usually be reduced or eliminated. Those who wish to see immediate action in terms of significantly increased services for persons with co-occurring disorders should consider advocacy at the Federal, State, county, and/or local levels to obtain increased appropriations to specifically support an expansion of these services.

Other barriers cited frequently by States include: (1) The need for additional appropriate resources beyond funding (e.g., housing assistance, appropriate facilities, staff in rural areas); (2) the need for education, training, and certification of AOD/MH treatment practitioners, and (3) the need for enhanced cooperation and coordination between the State AOD and State MH Authorities. Identified problems included differences in treatment philosophy (e.g., abstinence versus harm reduction, use of psychotropic medications with alcoholics or addicts), turf battles between agencies and practitioners, and ongoing issues such as the importance of increasing cooperation without violating client confidentiality.

Suggested methods to deal with these barriers ranged from improved and/or crossstaff training, to joint memoranda of understanding among relevant agencies, to pooled agency resources, to new program or practitioner certification standards that require both AOD and MH expertise for providers who may serve clients with co-occurring disorders. National leadership from agencies such as SAMHSA or CSAT on areas such as providing monies to States to support AOD/MH cross training for treatment staff could be helpful. Another approach might be to collect and share information among States in areas such as alternative options for meaningful and successful memoranda of understanding among various State and/or local agencies who could do more to support services to persons with co-occurring disorders. Over four-fifths of the State Agencies (82.9% of AOD Agencies and 85.2% of MH Authority respondents) reported the presence of policies, practices, and/or functions that support the delivery of appropriate services to clients with co-occurring disorders. These included: (1) Task forces that establish relevant policies and/or rewrite standards to require assessments for co-occurring problems; (2) co-location of AOD and MH staff, particularly those involved in the direct delivery of services to clients; (3) staff teams that jointly develop service delivery plans for clients; the implementation of workshops and conferences that address relevant issues and provide cross training of AOD and MH staff, and (4) the institution of pilot programs, along with the dissemination of information on those new programs and/or practices that are most successful.

In order to build upon and share successful State policies and practices such as those listed above, SAMHSA and/or CSAT may wish to develop and distribute one or more Treatment Improvement Protocols (TIPs) in these areas. However, since appropriate actions in many of these areas may be influenced more by attitudes than knowledge, it is essential that not only paper or even on-line documents be produced, but that face-to-face training workshops among AOD and MH policy makers and treatment practitioners at a State and local level be properly designed and instituted.

Domain 10: The State provides services targeting special populations with co- occurring disorders (e.g., HIV/AIDS, homelessness).

Over half of the State Agencies (51.2% of the AOD Agencies and 62.6% of the MH Authority respondents) reported that they provide services that target special populations with co-occurring disorders. Some of the special populations identified by various States include the following: persons with HIV; homeless and/or indigent persons; pregnant women and/or women with children; persons in the criminal justice system; youth; members of racial and ethnic minorities; elderly persons; and persons with severe and persistent mental illness.

This is an area where the development of one or more TIPs by SAMHSA or CSAT would be relevant and helpful in facilitating information exchange. This would also encourage State and local agencies and practitioners to implement more effective services for persons with co-occurring disorders in some of the targeted population areas. If additional monies or other resources could be provided to States to at least initiate pilot programs for these special need groups, such support would be appreciated by State Agency officials, by local providers, and by the clients who are the recipients of the services.



 

Recommendations for the Future

From the above analyses and discussions of the data from the ten basic information domains, as well as from input provided by a focus group of State Agency Directors and others, a number of different important recommendations emerge. These include the following:


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