OUTPATIENT QUALITY STUDY OF INTEGRATED TREATMENT OF MENTAL ILLNESS AND

SUBSTANCE ABUSE
A DISSERTATION SUBMITTED
Malachi Oledibe
January, 2013
School of Professional Psychology/School of Organizational Leadership
UNIVERSITY OF THE ROCKIES
CHAPTER II
LITERATURE REVIEW
The purpose of this chapter is to provide a review of the research works
done by other researcher in the field of diagnosis and treatment of
co-occurring disorders. This will provide a historical background of the
progress on the treatment of co-occurring substance use disorders and
mental illness. It will also provide a contextual framework within which
the current research is situated. The Chapter begins by defining the
significant terms in order to make it easy for the reader to understand
the content. This is followed by the discussion on the search techniques
used, prevalence of the co-occurring disorders, treatment, and the
alternative treatment programs available. Other topics discussed in this
chapter include the application of medical management in treatment of
co-occurring disorders and the challenges faced by people suffering from
co-occurring substance use addiction and mental illness.
The main sources of information in this chapter will be the published
journals and books, which address the topics of co-occurring disorders
and the suitability of different treatment models. This will provide the
readers of this research work with the overall framework and enable them
to place this piece of work in a given section of the large picture of
the available knowledge of co-occurring disorders and the effectiveness
of combined therapy (Chandler, 2010). The review of the available
research will help the reader identify the need for this research, which
will help in answering the two hypothetical questions including
How does the integrated treatment of co-occurring disorders enhance
treatment outcomes compared to the fragmented treatment models?
How does the fragmented/traditional treatment approach impede treatment
for individuals with co-occurring disorders?
The content of this chapter will attempt to identify the knowledge gaps
that exist despite the available research works in the same area of
study. According to Potter (2010) a review of literature may identify
the knowledge gaps in various ways including a lack of consistency in
the findings provided in the previous research works the existence of
flaws in the design, methods data collection, sampling techniques, and
interpretation of the findings other research works being conducted in
different populations and the uncertainties of the findings of the
previous research works. The chapter will provide an examination of
known ideas and facts about the effectiveness of the combined therapy
for treatment of mental illness and substance use addiction.
Definition of terms
Stigma- refers to the mark of disgrace associated with a given
circumstance, quality or a person (Oxford dictionaries, 2012). In the
context of the current research, the word stigma has been used with
regard to the disgrace that befalls the client with co-occurring
disorders.
Treatment philosophies- refers to the approaches used by the health care
professionals for treatment a given health condition or a disease based
on the professional understanding and experience (Blanco, Secade &
Nunes, 2012).
Supported employment- it is a training system, which supports people
with disabilities to help them continue with an ongoing employment. The
program provides vocational rehabilitation to individuals with
co-occurring substance use disorder and mental illness and helps them
believe that they can work competitively (Substance Abuse and Mental
Health Service Administration, 2010).
Medication management- refers to the process of monitoring medications
taken by the patients in order to confirm that they comply with the
medication regimen, thus avoiding adverse drug interactions (smith,
2012).
Polypharmacy- refers to the situation in which the patient takes a large
number of medications either to address a chronic illness or multiple
disorders (Smith, 2012).
Criminogenic- it is the tendency to produce a crime (Dictionary.com,
2009). The co-occurrence of mental illness and substance use disorders
creates a health condition that subjects the patient to engage in
criminal activities.
Schizophrenia- It is a mental disorder that affects the emotional
response of a person thus making it difficult to distinguish the real
and unreal things (Lyness, 2011).
Bipolar disorder- refers to a mental disorder that is characterized by
an abnormal shift in moods, energy, activity, and the ability to
complete the targeted daily activities (Nordqvist, 2012).
Search strategies
The prior planning of the search strategies for a review of literature
is necessary to ensure that the information obtained is relevant to the
topic of research (Potter, L., 2010). In addition, this ensures that the
information captures in the literature review unveil all the knowledge
gaps and identifies the similar research works, which helps to avoid a
duplicate research. To this end, various search techniques will be
applied in search for the relevant information for the accomplishment of
this chapter. The key information sources will include the relevant
database especially in the field of health and the printed materials,
which address the main topic of this research or its subtopics. However,
the validity of the chapter will be achieved by reviewing only the
published sources including the journals, books, and trusted website
contents. The search engine review was optimized through the Boolean
operations. This was achieved through the use of relevant keywords of
different subtopics, nesting, and phrases (Indiana State University,
2011). The key terms were obtained by subdividing the chapter into
different sub-topics, each of them addressing a different aspect of the
main topic. The most crucial keywords and phrases obtained included
“the prevalence of co-occurring disorders”, “effectiveness of
combined therapy for treatment of co-occurring disorders”,
“traditional models for treatment of co-occurring disorders”, and
“socio-economic consequences of co-occurring disorders”. The
historical seminal studies and theories related to the treatment of
co-occurring disorders were easily identified from the reliable
databases (such as PubMed and the US National Library of Medicine
National Institute of Health) using the key terms like “report”,
“study”, and “theory”. The previous studies considered in this
resembled the current research in several aspects such as scope of the
study, qualitative methodology, and techniques for statistical data
analysis. This chapter, similar to other chapters of this research
majored on the most recent works starting from 2009 to 2012. This is to
ensure that the research identify and address the most current
challenges in the treatment of the co-occurring mental illness and
substance use disorders.
Prevalence of co-occurring mental illness and substance use disorders
The co-occurrence of mental illness and substance use disorders presents
a radical challenge among the clinicians especially at the stages of
diagnosis and prescription of the appropriate treatment. This challenge
will persist given that the institutions offering the heath courses and
training will continue offering separate packages for the treatment of
mental illness and substance use disorders. Previous research works have
indicated an increase in prevalence of the co-occurring mental disorders
and substance use addiction. Genevieve & Pauline (2009) identified that
many people with co-occurring disorders are diagnosed with more than one
mental and substance use disorders. The research identified that 92 %
of the mentally ill patients admitted at the treatment centers had
disorders related to substance abuse. Among this research sample 23 %
were diagnosed with two, 33 % had three, and 8 % had mental disorders,
which co-occurred with substance use disorders. A study based in the
United States identified that over 8.9 million had co-occurring mental
and substance abuse disorders by the year 2009 (SAMHSA, 2009). In
addition, the study suggests that only 13.5 of this population have
access to the treatment services for both conditions 37.6 % had no
access to treatment for either of the disorders while 44 % received
treatment services for either of the disorder. Alergria, Hasin, Nunes,
Liu, Carrie, Grant & Blanco (2011) identified the existence of a strong
relationship between the generalized (GAD-SUD) anxiety disorder and
substance use disorders with a lifetime prevalence rate of 2.04 %. In
addition, the study identified that persons with the GAD-SUD had higher
comorbidity for psychiatric conditions compared to the general
population. All the subjects in the current study had been diagnosed
with axis 1 diagnosis from the DMS-IV. However, Alergria et al, (2011)
research had some limitations in the data collection techniques. The
study relied on the database of the National Epidemiological Survey on
Alcohol and Related Conditions (NESARC), which does not provide
information on co-occurring disorders for population in prison and
adolescent. This reduced the capacity of the study to acquire a
representative sample. Similar research, which aimed at identifying the
differences among the significant depressive disorders in both
conditions of presence and absence of co-occurring substance use
disorders and substance induced depressive disorders (MDD-SUD, MDD-NSUD,
and SIDD respectively) identified a lifetime prevalence rate of 7.41 %
for MDD-SUD and 5.82 % for the MDD-NSUD. In addition, the study
identified that persons suffering from MDD-SUD and SIDD were at higher
risk of contacting MDD that the general population. According to Blanco,
Secade & Nunes (2012) the high prevalence of MDD among the individuals
suffering from MDD-SUD increased their vulnerability to other conditions
such psychopathology, severe episodes of depression, and high rates of
attempts to commit suicide. All these factors aggravated the conditions
of mental illness and vulnerability to substance abuse. However, there
is no research that has identified a clear relationship between the
impact of co-occurring psychiatric disorders and the outcomes of
treatment of the substance use addiction. Recently, a few researchers
have attributed this comorbidity to the bureaucratic treatment models
leading to treatment dropout and inadequate treatment procedures that
result in relapse. The findings of similar studies, whose aim was to
establish the relationship between the psychiatric comorbidity and the
treatment procedure, contradicted these suggestions. The study could not
identify a significant relationship between the psychiatric comorbidity
and the likelihood of seeking for the treatment of co-occurring
disorders. However, the research was limited to the disorders related
to alcohol dependence.
Different researchers have also identified the crucial disorders, which
have a high probability of occurrences. However, many studies provide a
contradicting match between different categories of co-occurring
disorders. The most common disorders include the main depression
disorders with 57 %, general anxiety disorders with 20 %, and borderline
personality disorder with 16 % chances of co-occurring with substance
use disorders (Genevieve & Pauline, 2009). The research by Genevieve &
Pauline (2009) relied on a sample of subjects aged between 18-65 years.
However, a slight difference from the current research arose from the
data collection and recording technique. The researchers used personal
interviews and clinical testing to collect data. The GOHAI
questionnaires and Arabic OHIP-14 were used to record the data. These
techniques were relatively similar to the techniques used in the current
study. The use of predesigned questionnaires and rubrics is the most
suitable in collection of data based on human behavior (Genevieve &
Pauline, 2009). Substance Abuse and Mental Health Service Administration
(2009) identified that 45 % of the adults diagnosed with the
co-occurring disorder in the United States had more than one chronic
condition. About 24 % of this population had psychiatric conditions,
central nervous disorders, and cardiovascular disorders. A retrospective
cohort research, which studied the risk of re-incarceration among
persons with co-occurring severe mental and substance use disorders in
Brazil identified that the psychiatric disorders are a significant
challenge among this population. According to Baillargeon, Penn, Knight,
Harzke & Becker (2009) some of the most occurring psychiatric disorders
include the principal depressive disorder, bipolar disorder, and
schizophreniform disorder. These disorders were detected to be
co-occurring in 7.4 % of the study population. The study further
suggested that the prevalence of the psychiatric and substance use
disorders were higher in female subjects 15.7 % than in their male (5.9
%) counterparts.
Some studies have identified the relationship between serious mental
disorders such as bipolar and substance use disorders. According to
Michael & Ostacher (2011) there is limited attempts among the
researchers to identify a clear link between the co-occurrence of
bipolar and substance use disorders. Nicotine and opiate addicts are at
a higher risk of contacting the bipolar I and bipolar II than the
general population. The study identified that the 5 % of the alcohol
dependence persons suffered from bipolar, 31 % from significant
depressive disorders, and 30 % from anxiety Michael & Ostacher (2011).
The study used a sample size of 166 subjects. The researcher used the
PGWBI questionnaires to record the qualitative data similar to the
current research. However, additional techniques of data collection and
recording including the CQ7 and the MOS sleep questionnaire were used.
Persons suffering from bipolar disorders present with earlier onset of
the disorder, frequent attempts to commit suicide, reduced adherence to
treatment, poor psychosocial functions and reduced response to
treatment. However, the researcher confined the high prevalence of
co-occurrence of nicotine and opiate addictions and bipolar disorders,
but failed to address the effectiveness of combined therapy for the two
categories of disorders. Bipolar disorder occurs in conjunction with
other disorders of drug abuse including depression, anxiety, cognitive
disorders, impulsive control disorders, and personality disorders. In
addition, the cost of treating the co-occurring disorders is higher
compared to treating one disorder at a time.
The researcher has revealed that young people (aged 24 years and below)
under treatment for mental illness are at higher risk of engaging in
substance abuse than the patients of other higher age groups. Tate,
McQuaid & Granhol, 2012) identified that 43 % of the young people
receiving treatment for mental illness have other disorders related to
substance abuse. Similarly, the study indicated that the youths who
abused drugs such as marijuana, cocaine, and alcohol experienced mental
disorders including mental depression. The co-occurrence of substance
addition and mental illness among the youths subjected them to risks
such as suicidal ideation, homelessness, incarceration, and suicide
attempts. The co-occurrence of mental illness and substance use
addiction affects women at a higher rate compared to men. About 84 % of
the women under treatment for mental illness experienced substance use
disorders. Consequently, the study indicated that women with c-occurring
disorders are at a higher risk of committing suicide. The immaturity of
brain development coupled with co-occurring disorders worsens the health
condition among the young people. It subjects them to frequent conflicts
with the criminal justice system, suicide, and victimization.
Treatment of co-occurring disorders
In spite of the many decades of established relationships between the
mental illness and substance abuse, there are relatively few effective
models to counter the condition. Burnam & Watkins (2012) reported that,
before the development of the integrated dual disorder treatment (IDDT)
in 2003, the health practitioners could only use unscientifically
supported means of convincing patients of the importance of avoiding
substance abuse. The common knowledge among the health specialists was
that substance abuse was not good for the patients because it
exacerbated the symptoms of mental illness. Couwenberg, Gaag, Koeter &
Brink (2009) eliminated the existing doubts about the relationship
between the drug abuse and mental illness. The research found that
persons with mental illness, especially the schizophrenia, had 50 %
prevalence to substance abuse compared to 15 % of the general
population. Additionally, the study suggested that the earlier methods
of treatment for the co-occurring disorders lost the focus because they
segregated the mental health care and addiction treatment. Grella (2009)
reported that most of the approaches used in treatment of dual disorders
are informal and fails to adhere to the scientifically driven
procedures.
It is evident from the previous studies reviewed in this research that
co-occurring mental and substance abuse disorders are significant
challenges in the world (Nunes, Selzer, Levounis & Davis, 2010). Some of
researchers have suggested that patients’ have limited access to
effective treatment (Chandler, 2010 & Lyness, 2011). Some of the
challenges that deny the patient access to treatment include their
involvement in criminal justice, homelessness, and health status. The
efforts to reduce the both systematic and unsystematic barriers can
provide a long lasting solution to the rising trend in the population
with co-occurring disorders. This is because the early diagnosis and
treatment of the co-occurring disorders have the capacity to reduce the
severity of the disorders and the probability to relapse. The delay in
the diagnosis and the onset of the treatment process prolongs the
recovery for the co-occurring disorders.
The design and implementation of an effective treatment plan has the
capacity to reduce and counter the challenge of the high number of
persons surviving with the co-occurring disorders (Noordsy & Mueser,
2010). An effective treatment model must comply with two key principles
that can help it improve the treatment and recovery process. The first
principle dictates that the treatment plan should provide for continuity
of care over time. This implies that the health care providers must
recognize the fact that treatment may take place in an outpatient or
residential settings while recovery process occurs outside. In addition,
the recovery process is determined by other factors such as
participation in the self help groups, family, community, and religious
organizations. The second principle states that treatment interventions
should be devised specific to the task and be tailored to face the
challenges at all stages of treatment and recovery. The clinicians and
psychologists attending to the mental and substance abuse disorder
should use sensible stepwise approaches in the development and
application of treatment protocols. Moreover, they should consider
unique markers related to culture, religious, and social contexts
(Braude & Niki, 2011).
Different researchers have provided contradicting reasons for the high
rate of increase in the incidents of co-occurring disorders. According
to Poling & Levinson, (2009) serious mental illness and substance use
disorders results from the disruption of personal and social life, thus
an effective medical plan should address the two disorders concurrently.
Moreover, the treatment plan should be extended to finding the solution
to the underlying personal and social life problems. Addressing the
underlying issues is the prerequisite to getting the client engaged in
continuing the treatment and behavioral change. To achieve the desired
effect, the treatment program for the mental illness and substance use
disorders program should include other professionals. Moreover, the
services of the psychiatrists in the sustaining the recovery and stable
functioning of the persons diagnosed with co-occurring disorders are
inevitable (Chudzynski, 2010). The addition of an on-site psychiatric
service in evaluation and prescription of medicine decreases the
substance use and enhance treatment retention. This is one way of
integrating the services for required in the treatment of persons
suffering from co-occurring disorders because it reduces the barriers of
off-site treatment plans. The main challenges of the off-site referral
include the travel costs, discomfort of being served by different staff,
and inconvenience of enrolling in separate agencies. Lack of resources
such funds is a significant challenge, which has hindered the
development of effective treatment models for the treatment of the
co-occurring disorders. The insufficiency of resources has limited
capacity of the facilities to the consultants of the highest caliber who
could facilitate the integration of the traditional treatment plans in
an effective way. These challenges often subject the patients to the
risk of treatment dropout and relapse. Chandler (2010) studied the
recovery progress of patients with co-occurring mental and substance
used disorders and compared to the recovery of each of the disorders
separately. The research findings indicated that individuals with
co-occurring disorders are vulnerable to relapse and increase in
psychiatric disorders. The addition relapse often results in psychiatric
decomposition, which consequently leads to addiction relapse. These
challenges were attributed to the bureaucratic treatment models, which
subjects the patients suffering from co-occurring disorders to the risks
of treatment dropout and relapse.
Barriers to accessing treatment:
There are several factors, which hinder access to treatment among the
population of people with co-occurring mental illness and substance use
disorder. Cohen (2010) reported that the substance use disorder and
mental illness are associated with a high level of stigma in the
society. Consequently, persons suffering from the two disorders, both
individually and in co-occurrence shy away from visiting medical
centers. Stigmatization among the people suffering from co-occurring
disorders has proceeded for decades despite a pool of research, which
disapproves the public opinion that the co-occurring substance use
disorders and mental illness results from personal failings and moral
misconducts. In addition, both private and public insurance policies
have neglected the two disorders on the perception that their occurrence
is not similar ton common diseases. This results in the disqualification
of consumers with mental illness and substance use disorders from
insurance funding programs, thus limiting their access to quality
treatment.
Secondly, the limited number of professionals for either of the mental
illness or substance use disorders limits the opportunities for patients
to acquire the suitable medication (Cohen, 2010). This is a significant
challenge especially when integrating the mental health and substance
abuse treatment. It is extremely difficult to find health professionals
who are trained to handle the two co-occurring disorders. Additionally,
the separate licensing of the health professionals for mental health and
substance use addiction treatment limits the number of professionals who
can handle the two disorders holistically. The available staff at times
lacks adequate resources to provide the necessary treatment to the
clients. The fragmented nature of the available treatment facilities,
couple with the health professionals with qualifications for treatment
of separate disorder results to the frustration of the consumers. This
is because the patients have to seek for medical attention from
different groups of providers in separate locations.
Traditional models for treatment of co-occurring disorders and their
limitations:
The treatment services of mental illness and disorder that result from
substance abuse have been offered in different settings. Despite the
clear evidence presented in the previous studies indicating that the two
disorders are co-occurrence, some stakeholders still believe that they
should be attended under different settings by different health care
providers (Gulliver, 2010). The traditional approaches that have been
used in the past in treatment of co-occurring disorder include the
sequential and parallel treatment model. Under the sequential model, the
client is treated for one disorder and then referred for the treatment
of the other disorder in a different system. In most cases, persons
suffering from co-occurring mental illness and drug addiction refer to
the drug addiction treatment systems before commencing the treatment of
mental illness (Gulliver, 2010). Patients under the sequential treatment
model do not receive adequate health care because of the
non-simultaneous participation between the two systems. Parallel
treatment model, on the other hand, patients suffering from co-occurring
disorders are attended both mental and substance use addiction systems
simultaneously, but by different health care providers.
Some proponents of separate treatment models argue that treatment of
serious mental illness should be initiated after abstinence from
substance use has been achieved (Braude & Niki, 2011). The other group
of opponents argues that patients suffering from co-occurring serious
mental illness and substance use disorder are so volatile to be attended
in substance use settings. The government policies have played a vital
role in the development of separate treatment models for the serious
mental illness and substance use addiction. This is done through the
provision of funds in different streams for substance abuse treatment
health. Moreover, the responsible authorities in the health dockets have
licensed and providing credentials to health care providers and
clinicians separately. This has propagated the separate treatment
philosophies and practices in the field of co-occurring disorders.
Different researchers have suggested several problems that arise when
treatment of co-occurring disorders is done under separate settings.
According to Poling & Levinson (2009) the sequential treatment model
subjects consumers to the high risk of return to drug abuse. Despite the
status of complete abstinence achieved under the sequential treatment
model, there is rising fear that the prescribed medication to treat
mental illness could result in relapse to drug addiction. Health care
attendants in the mental often fail to comprehend the addicted consumers
and the patients under the recovery process because there is limited
simultaneous participation between the two settings. This results in
prescription of drugs with a high potential for abuse, thus increasing
the chances of relapse to substance abuse. Putting on hold at the
expense treating the other disorder may not be the best practice. Lyness
(2011) identified that while treating one the disorder, the disorder
that is put on hold worsens the other one, thus resulting in prolonged
recovery process and poor lifestyle of the client. It is also difficult
to decide on the disorder that should be treated first between substance
use addiction and mental illness. In most health centers, clients are
referred from one setting to the other for stabilization of at least one
of the disorders before they can receive treatment for the other
disorder. The health care professionals find it difficult to determine
when the disorder under treatment is stabilized so that the treatment of
the other disorder can commence.
The parallel treatment model, which involves the treatment of the two
disorders (that is a mental illness and substance use disorders) at the
same time by different health care providers and different settings,
subjects the clients to a series of challenges. The nature of the model
limits the integration of the substance abuse treatment and mental
health into a coherent treatment package. This results in health
challenges remaining unnoticed and unattended because of the limited
communication between the treatment providers. In addition, different
health care providers use varying approaches to treat disorders. Lack of
a common language and treatment approaches among the health care
providers frustrate the client and limit the outcome for the treatment
for either of the disorders. Moreover, health care providers often give
contradicting recovery reports under the separate treatment models
(Gulliver, 2010). This is because the treatment and recovery process for
the two categories of disorders takes varying durations, thus subjecting
the consumer to further confusion.
The concept and the benefits of an integrated model for treatment of
co-occurring disorders:
Currently, the integration of mental health and SAT services is a
controversial issue. This presents a lot of structural barriers, which
have delayed the adoption of a holistic treatment of the mental illness
and disorder that result from drug abuse. Gulliver (2010) stated that
understanding the potential benefits of an integrated treatment model is
the prerequisite step in the adoption of a holistic treatment plan for
the co-occurring disorders. Integrated treatment model combines the
treatment services for people suffering from both serious mental illness
and substance use disorders at the same time. The integrated treatment
model for the co-occurring disorders allows clinicians to provide mental
illness and substance abuse interventions in a holistic fashion.
Nordqvist (2012) suggested that successive integration of treatment
models for co-occurring disorders includes the combination of three main
service structures. First, in the integrated treatment model, the
centrally assessment unit is equipped with cross trained staff and
unified assessment instrument that seeks to meet all the regulatory
requirements. Secondly, the integrated treatment plan provides a single
point assessment and co-location of agencies in a single building. This
eliminates the referral of consumers from one setting to the other,
which is a common practice in the fragmented treatment models. Third,
the integrated treatment provides a multidimensional and holistic
treatment process. This ensures that the patient needs are addressed
within the context of their biopsychosocial history.
The main objective of the integrated treatment model is to improve the
recovery of two co-occurring illness. This is made possible by providing
the treatment in a stage-wise fashion, whereby some services are
provided earlier while others are provided later in the treatment
process. The integration of the two settings begins by identifying the
challenges presented by the prevailing treatment plans and delineation
of strategies to overcome the challenges (Gulliver, 2010). The define
strategies should describe the core competencies and training programs
for the mutual benefit of both the treatment professionals and their
clients. The integration of the mental illness and substance abuse
treatment settings can result to synergistic benefits. The integrated
plan has the capacity to expand the effectiveness of the two treatment
programs individually. In addition, the integrated treatment model
provides an effective pathway for consumers to move between services and
transition from active treatment to community support system.
The integration of substance and mental illness treatment interventions
involves the collocation of the staff and treatment facilities from the
two settings. The merging of the two settings benefits both consumers
and healthcare providers. First, it results in sharing of resources and
services such as supervision, which ultimately reduces the cost
delivering the treatment services. Secondly, the combined therapy for
substance use disorders and mental illness facilitates the provision of
an on-site psychiatric consultation. This reduces the level of
frustrations that result from the parallel and sequential treatment
models in which psychiatrist and consumers are forced to move from one
setting to the other. According to Braude & Niki (2011) the fragmented
treatment model has limited outcome because the health care providers
and clinicians use different philosophies and approaches to treat the
co-occurring disorders. However, the integration of the two settings
creates an opportunity for the staff in mental and substance use
disorder to identify the differences in the treatment approaches,
philosophies, and professional backgrounds. This helps the members of
staff and the administration of both settings to focus on shared
clients, a strategy that improves the treatment outcome. Moreover, the
integrated treatment model offers an opportunity for the staff of both
settings to socialize, thus fostering teamwork and sharing of treatment
philosophies and skills.
Currently, there is sufficient evidence that the integrated model for
treatment of co-occurring disorders are more effective compared to the
traditional models, which include the parallel and sequential treatment
plans. Braude & Niki (2011) reported that the integration of the two
treatment settings reduces the philosophical barriers and strengthen the
relationship between the providers of the mental illness and substance
abuse treatment interventions. This results from the elimination of
administrative and organizational lapses and the need for the decision
on which of the two disorders is primary. In addition, the integration
eliminates the need for referrals and results in the provision of a
single treatment and assessment and recovery report.
Despite the variations in the benefits identified in various research
works, the majority of the available studies show that the integrated
treatment is more beneficial compared to the fragmented treatment
models. Mueser, Frisman, Covell, Crocker & Sack (2009) analyzed the
effectiveness of integrated dual disorder treatment among 36 persons
suffering from antisocial personality disorder (ASPD) co-occurring with
alcohol addiction disorders and a control group of 88 persons without
ASPD. The researcher identified that the integrated interventions were
effective in the treatment of the co-occurring disorders especially when
offered through the assertive community treatment (ACT). An integrated
treatment of defects of cognitive behavior is effective compared to
separate treatment of substance abuse. McGovern, Lambert, Alterman,
Haiyi & Meier (2011) used a randomized controlled trial to establish the
effectiveness of the combined therapy for treatment of persons with
co-occurring post traumatic stress disorders (PTSD) and substance use
disorders. The research involved an introduction of participants from
seven community addiction treatment programs in an integrated therapy
program. The research results indicated that integrated therapy could
reduce the PTSD re-experiencing symptoms and PTSD diagnosis more
effectively than an individualized treatment plan. SAMHSA (2011)
reported that the integrated treatment interventions improve the
treatment outcome by reducing the symptom severity, improving the
treatment response, and reducing remission response.
Approaches to integrated care for treatment of co-occurring disorders:
Different researchers have established that integration of the treatment
interventions results in better treatment outcome and lifestyle of
persons suffering from the co-occurring mental illness and substance
abuse disorders (Gulliver 2010 and Sterling, Chi & Hinman 2010). Despite
the fact that the several researchers have identified the need for the
integration of the treatment of the two categories of disorders, there
is still a significant challenge about the approach towards the
integration of the two health care settings. This is partly because
there are several barriers (such as philosophical and differences in the
treatment approaches) in the two settings and the limited data on the
suitable approaches to guide the integration process. An appropriately
designed approach to the integration process should target at providing
what is best for the consumers, general population, and establishing a
relationship between the staff of the two settings (SAMHSA, 2011).
Prior definition of the objectives and the evaluation criteria are the
prerequisite towards the design of the suitable strategies for the
implementation of an integrated health care for treatment of
co-occurring disorders. Baillargeon et al (2009) suggested three guiding
principles to facilitate the design of the most appropriate approaches
of the integrated treatment for the co-occurring substance abuse and
mental illness disorders. First, the stakeholders in the health
department should target the individual comprehensive needs. This means
the strategy should be consumer oriented to ensure that the strategy
provides maximum benefits to consumers by countering the challenges
presented by the fragmented treatment models. Secondly, the stakeholders
should define the means of evaluating the outcome of the integrated
model. This is significant in ensuring that the integrated model offers
the benefits such as improved outcome, reduced cost of treating the
co-occurring disorders, and minimize the frustrations caused by the
fragmented treatment models (SAMHSA, 2012). Lastly, the prior
arrangement of the integrated funding principles is a significant
milestone towards the integration of the two settings. Different
research has identified that provision of separate funding schemes is
one of the major barriers towards the integration of the two health care
units.
The main goal of integrating the treatment interventions for substance
abuse and mental illness is to reduce the consumer referrals, thus
improving the treatment outcome as well as reduce the rate of treatment
drop out. The other goal is to improve the quality for individuals
suffering from co-occurring disorders. The treatment services for the
mental health and substance abuse treatment settings can be integrated
in two approaches. The integration depends on the level at which the
merging occurs. The service integration at the provider level has been
used for decades since the discovery of the high rate of prevalence of
the co-occurring disorders (Mueser, 2009). This includes the integration
of services within parallel and sequential treatment. The efforts
applied in this approach of integration include the cross-training of
providers, locating practitioners of one care into the other setting.
This approach aims at establishing a stronger relationship between
fragmented programs improve communication about referral and treatment
progress within independent settings, definition of responsibilities and
service eligibility criteria, and reducing the philosophical barriers
between the two independent settings. However, research has established
several weaknesses in this category of integration. The integration at
the provider level could not effectively remove the philosophical and
organizational barriers. In addition, the approach cannot establish an
effective collaboration between the professionals of the mental health
and substance abuse treatment.
Researchers have suggested that the integration of the mental health and
substance abuse treatment settings should be integrated at the client
level (Cohen, 2010). The opponents of these suggestions argue that the
integration should be client oriented and should thus aim at maximizing
the benefits offered to the client. The integration of the two settings
at the client level involves the provision of the mental health services
and substance abuse treatment by the same providers in a single setting.
This involves a comprehensive merging of administrative, health care
providers, and resources to improve the treatment outcome. The
comprehensive integration eliminates organizational, administrative, and
philosophical barriers. In addition, research has identified that the
integration at the client level improves the treatment outcome, reduce
the cost of treating co-occurring disorders, treatment dropouts, and the
frustrations caused by the fragmented models of treatment of
co-occurring disorders.
Barriers to integrated treatment:
It is evident that integration of treatment interventions at the client
level is the best option that can guide towards optimization of
treatment for co-occurring substance use disorder and mental illness
(Blanco, 2012). Despite the availability of several research works,
which indicates that the integrated treatment of co-occurring disorders
improves the treatment outcome for the patient, the efforts to integrate
the two settings at the client level face several challenges. First,
separate funding streams for the mental health setting and substance use
setting presents some difficulties in merging the two units. Different
governments in the world have separate funding schemes for mental
illness and substance use treatment. This separation arises from the
perception that the two settings have varying needs in terms of
facilities and treatment cost per head. Apart from the constraints
presented by the budget allocations, there other barriers that are
caused by state regulations. For example, social security regulations in
the United States are discriminating because they treat the consumers
suffering from substance abuse disorders as ineligible for supplemental
security income (SSI) (Blanco, 2012). This limits the consumers with
disorders that result from substance abuse from accessing the publicly
funded treatment services. The discriminating medical funding funds and
benefit schemes make the merging of the mental health and substance
abuse treatment units difficult. The current efforts to provide joint
funds for mental health and SAT are not sufficient to facilitate the
integration of the two settings at the client level. This is because the
broadened medical programs that attempt to cover the two categories of
disorders provide financial support to the fragmented treatment
settings. This does not solve other challenges such as philosophical,
different practices, and administrative confronts.
Secondly, the variations in the treatment philosophies, in the substance
abuse treatment and the mental health unit, presents a considerable
challenge in merging the two settings. The major reasons for the
divergence in the treatment approach applied in the two settings results
from the origin (Nunes et al, 2010) identified that the mental health
treatment has a stronger attachment with the formal treatment models,
where formal training in social work, psychology, and psychiatry, are
playing a key role in advancing the mental health setting. On the other
hand, treatment of substance use addictions resulted from the community
based movements. The treatment of substance abuse disorder is mainly
centered on rehabilitation of the culprits with the contribution of
community support. The difference in the treatment philosophies applied
in the treatment of the substance disorders and the mental health
disorders leads to deployment of professionals of different calibers,
which further complicates the merging efforts. However, these
philosophical differences can be reduced through the development of
institutional capacities, training the practitioners on the modern
treatment practices. The shared perspective among the practitioners in
the two treatment settings can be enhanced through joint educational
training programs and promotion of the task force. This provides
guidelines on the most effective means of integrating the two settings
and establishing sustainable coherence between the staff of the two
settings. There is a need to provide web based training programs to
equip the health care providers in the two units with emerging skills
and practices in holistic treatment of co-occurring disorders (Osilla,
Herpner, Munoz, Woo & Watkins, 2009).
Despite the agreement among the researchers that the integrated
treatment model is the solution to the challenges presented by the
fragmented treatment models, lack of resources is still a considerable
hindrance for the integration of the two settings. Limitation of the
resources available results in reduced capacity for training the service
providers in the principles and practices of treating the mental illness
and substance use disorders simultaneously. Staff training is one of the
success factors in the integration of mental health and substance abuse
treatment settings. Osilla et al (2009) reported that lack of money,
time, and incentives have played a crucial role in deterring the
training of staff in an effort to integrate the interventions for
treatment of mental illness and treatment of substance use disorder.
The requirement for additional funding and provision of other resources
results from the fact that the integrated model will require incentives
during the implementation and efforts to make it feasible.
The traditional models for the treatment of co-occurring substance use
disorders and mental illness have separate administrative structures.
The administrative bodies for the two settings were formed before the
need for integration arose in order to manage the workflow and funds
that were issue separately. Consequently, this has resulted in the
formation of separate licensing and accreditation policies for the
health care providers of the two settings. The differences in the
regulatory environment pose a significant challenge in the efforts to
integrate the interventions for the treatment of the two co-occurring
disorders. According to Braude & Niki, (2011) the administrative
barriers can be reduced by targeting the management information system
and policies governing the licensing of the mental health and substance
use disorders workforce. However, apart from cross-licensing the
workforce in the mental health and substance abuse treatment settings,
the integration efforts should begin from the training programs. This
means that the stakeholders should ensure that the training programs
equip the health professionals with the skills to attend to the two
categories of disorders simultaneously. Moreover, the integration and
up-grading of the management information system is necessary to ease the
assessment of the consumers seeking for treatment in the integrated
treatment model. This can make it possible to monitor the trend of the
co-occurring disorders, recovery, and aid in identification of the areas
where change is necessary.
Principles and the key success factors in an integrated treatment model
for co-occurring disorders:
Research has shown that the fragmented treatment models for mental and
substance use treatments are characterized by poor treatment outcome
(Mueser et al, 2009). Various principles have been suggested to guide
the process of integrating the two settings. The main goal of
integrating interventions for the treatment of mental illness and
substance use disorders is to provide better services to consumers. This
is achieved by treating the clients in one setting and by the same group
of health care providers. To achieve this, there is a need to develop
the key principles that will govern the stakeholders (including the
clinicians, nurses, health care providers, psychologists, and policy
makers) in the health dockets in assuming the shared responsibility. In
addition, the principles should guide the stakeholders in designing the
suitable approaches that will facilitate the utilization of available
resources collaboratively and identifying the plans that cannot be
implemented with the available resources.
The guiding principles towards the improved service delivery in the
treatment of co-occurring disorders are the comprehensive integration of
the service system of the mental health and substance abuse treatment.
The development of a conceptual framework for the integration of the two
settings is essential in the advancement of the integrated approach that
advocate for the commonality of funding schemes, treatment philosophies,
and resource sharing. In addition, the conceptual framework is essential
in ensuring that each consumer has an assigned clinician to monitor the
treatment and recovery progress of the two disorders. This ensures that
each of the clients receives the treatment interventions, which
considers all the potential complications that result from the
co-occurrence of disorders. The ultimate result of these efforts is the
improved treatment recovery and treatment outcome because each consumer
is given an individualized attention for the two disorders concurrently
(Genevieve & Pauline, 2009).
Research has shown that the continuity of the integrated treatment of
co-occurring substance abuse disorders and mental illness have the
capacity to improve the treatment outcome, reduce the costs of service
utilization, and incidents of relapse. The persistent and recurrence of
the psychiatric disorders necessitates the continuity of the integrated
treatment interventions to offer intensive treatment at any point in
time. To ensure continuity, the treatment interventions for the
co-occurring disorders are offered in stage wise model. The key phases
of the integrated treatment model include the acute stabilization,
motivational enhancement, active treatment that maintains the attained
stabilization, rehabilitation efforts, and evaluation of the recovery
process (SAMHSA, 2012). However, the phases of treatment may not be
sequential because the approach varies with several factors such as the
phase and severity of psychiatric disorders.
The recovery process in an integrated treatment model should be
accompanied by motivational efforts. This is because persons suffering
from co-occurring substance use addictions and mental illness are
characterized by lack of self esteem, loss of sense of self worth, and
dignity. The recovery aims at improving the lifestyle of patients by
restoring their sense of self worth and increasing the capacity of
patients to maintain stabilization of the disorders. These efforts help
the patients in gaining hope, a meaning for life, and develop the
capacity to endure dual recovery by overcoming the pessimistic attitudes
among the persons suffering from the co-occurring disorders (Gulliver,
2010).
Improved accessibility of the treatment services for the co-occurring
disorders is inevitable in achieving an effective integrated treatment
model. The fragmented treatment plans contribute to unavailability of
the treatment services for the co-occurring disorders. For example, a
parallel model provides the treatment of a single disorder and the
consumer is referred to a different setting for the treatment of the
other disorder. The sequential model, on the other hand, unavailability
of the treatment services arises because one of the disorders (mental
illness) cannot be attended by the other one (substance abuse) is
stabilized. An integrated treatment model ensures that the crises
resulting from co-occurrence of disorders are attended as soon as they
occur (Michael & Ostacher, 2011). In addition, the integrated model
ensures that patients are accepted at the treatment centers without the
need to self-define themselves for evaluation and treatment. An
effective integrated treatment model ensures that the consumer contact
with the health care providers ids welcoming, culturally sensitive, and
motivational.
The flexibility associated with the integrated treatment model ensures
that the health care providers attend to the needs of the patient other
than the consumer fitting in standard treatment protocols. This results
in the individualization of the treatment interventions, whereby the
services are tailored to the requirements of each consumer (Michael &
Ostacher, 2011). In an integrated treatment model, each consumer is
assigned to a single or a group of health care providers to monitor
their treatment and recovery process.
Braude & Niki (2011) identified that some consumers have two to four
mental and substance use disorders co-occurring. To this end, the
integrated treatment model should be comprehensive to cater for the
diverse needs (including the primary treatment and behavioral health
care) of patients. To achieve this, the integration process may require
a complete integration of mental health and substance use treatment
programs. Other measures to achieve a comprehensive integrated treatment
model include the cross-training of staff or creating teams of providers
to attend to the needs of each client at the each level.
Consequences of co-occurring mental illness and substance use disorders:
The co-occurring disorders have a direct impact on the patient and
indirect impacts on the members of society closer to the patients. The
patients` relatives have the responsibility to offer motivational care
of the patients during the recovery process. This is because their
support contributes much in restoring hope and the sense of self worth
to the patients. Persons with co-occurring substance use addiction and
mental illness have social, emotional, and severe medical problems
compared to people with one disorder and people with none (Blanco,
Secade & Nunes, 2012). Consequently, this population experience adverse
impacts such as elevation of psychiatric disorders, psychiatric
decompensation, reduced social-economic productivity and vulnerability
to addiction relapse. In addition, research shows that patients with
co-occurring disorders require a longer treatment period and recovers
gradually compared to patients with a single category of disorder. The
recovery process is gradual when the patients undergo the treatment
process in traditional models of treatment (parallel and sequential).
This is because the traditional treatment models do not offer continuous
medical attention, individualized health care, and a consistent
evaluation of the recovery process.
Persons suffering from co-occurring disorders often exhibit abnormal
behavior such as increased propensity to violence and failure to comply
with medication. People suffering from co-occurring mental illness and
substance use disorders have a higher rate of arrests and conflicts with
the criminal justice system than the general population. This
necessitates the support of other people to help them comply with the
medication and avoid conflicting with the legal systems. The need for
regular control of the behavior of the patients increases the number of
people affected (not just the close relative, but also other members of
society) by the co-occurrence disorder. Baillargeon, Harzke & Becker
(2009) investigated the rate of conflict with the criminal judicial
system among the population of people suffering from co-occurring
disorders. The research aimed at identifying the rate at which the
prisoners in the Unites States are at a risk of re-incarceration. The
study sample comprised of individuals suffering from co-occurring
disorders such as schizophrenia, significant depression disorders,
bipolar disorders, and substance use disorders. About 52.33 % of the
person suffering from co-occurring substance use disorders and mental
illness had one experienced incarceration. An evaluation of the rate
of re-incarceration revealed that 19.77 % of this population had been
re-incarcerated at least once while 6.8 % had been re-incarcerated at
least twice. In addition, the researcher identified that the
co-occurrence of disorders subjected the patients to the risk of
violence, homelessness, and suicide. The study was in agreement with the
findings of Osher, Amara, Martha, Nicole & Eggleston (2012), which
indicated that 17 % of the total population of the persons in United
States jails in 2012 suffered from serious mental illness. Among this
percentage, 72 % suffered from co-occurring substance use addiction and
serious mental illness. In addition, persons suffering from co-occurring
disorders take a longer period of incarceration of persons with one
disorder. This is because, people with co-occurring disorders present
difficulty in correctional supervision compared to people with a single
disorder and the general population. The co-occurrence of disorder
results in functional impairment that reduces client response to
treatment and recovery interventions.
The co-occurrence of substance use disorders and mental illness results
in functional impairment, which subsequently reduces the economic
productivity of the patients. According to Biegel (2009) individuals
with cognitive and physical comorbidities have less intellectual ability
and productivity at work. Their productivity reduces in terms of the
number of working hours and outcome. However, their productivity can be
improved through supported employment and tailored services. However,
people with serious mental illness co-occurring with substance use
disorders often have chronic medical conditions, which impair their
vocational performance. This category of patients may not benefit from
the supported employment and end up losing jobs if they had any.
However, Biegel (2009) could not identify a significant difference
between the productivity of people with co-occurring disorders and
people with mental illness alone. The comorbidities affect physical
functioning of people with co-occurring disorders reduced earnings,
working hours, and competitiveness at work. People with co-occurring
disorders have continued to lose opportunities in the vocational
services despite the fact that a few research works indicate poor
productivity of this population. While exploring the enrollment of
clients with co-occurring disorders in supported employment services,
Frounfelker, Wilkniss, Gary, Devitt & Drake (2011) identified that
people with co-occurring disorders had fewer chances of getting
vocational vacancies by 52 % compared with the general population.
Productivity and competitiveness of persons with co-occurring disorders
was only 3 % less than the competitiveness of people without the
co-occurring disorders. The exclusion from vocational services subjects
the clients with co-occurring disorders to financial difficulties. In
addition, persons with co-occurring disorders need employment
opportunities to provide them with a meaningful activity that supports
their recovery process. Supported employment programs have the capacity
to offer the population of people suffering from co-occurring disorder
with employment opportunities. The key elements of supported employment
include job development tailed to individual needs, rapid job search,
and integration of vocational services and treatment for the
co-occurring disorders. However, the research indicates that few people
enroll in the programs because there are several challenges in the
enrollment process. Lack of residential places for the enrolled people,
fear of self-stigma, and less funding are some of the drawbacks towards
the enrollments in the supported employment (Lisa, Dickerson, Bellack,
Dwight, Goldberg, Lehman, Tenhula, Calmes, Pasillas, Peer & Kreyenbuhl,
2009). The support employment program helps the client to maintain
competitive employment despite their medical conditions.
People with co-occurring mental illness and substance use disorders find
it difficult to establish social relationships. They often live in a
marginal neighborhood because they fear stigmatization from the general
population. Some people with the co-occurring disorder find it easier to
establish relationships with drug users, who subject them with higher
risk of substance abuse and relapse to addiction. Moreover, the
population of people with co-occurring disorders are at higher risk of
contracting other common diseases that the general population (Noordsy &
Mueser, 2010). This increases the medical expenses as a result of
regular hospitalization.
Outcome of an integrated treatment model:
Proper implementation of integrated treatment model results in improved
lifestyle and recovery compared to the fragmented models. Integration of
mental health and SAT reduces the gap in service delivery, thus
ensuring an effective treatment of two disorders. This is because the
each client is serviced by the same providers or a group of providers,
who have an opportunity to identify all the health challenges facing the
consumer as a result of both disorders. Chung, Domino & Morrissey
(2009) studied the effectiveness of an integrated treatment model in
treatment of co-occurring disorders among women who suffered from
co-occurring mental illness and engaged in substance abuse following
sexual violence. The researcher identified that the integrated
interventions resulted in improved trauma-informed and quality service
for simultaneous treatment of the two disorders. The researcher reported
an increase an improvement in clinical outcome for treatment of
substance use addiction and mental illness. Chung, Domino & Morrissey
(2009) relied on the clients’ self reported data as compared to
provider reported data. This improved the validity of the research in
measuring the effectiveness of the integrated treatment model in the
treatment of co-occurring disorders.
The comprehensive nature of the integrated treatment model enables the
health care providers to address a broad array of challenges that might
prolong the recovery process. Apart from the mental illness and
substance use addiction, there are other factors, which contribute poor
health conditions of the clients. Health practitioners in an integrated
treatment model address other factors such as vocational functioning,
housing, social relationships, and housing of the client. The holistic
approach applied in the integrated treatment plan reduces the recovery
period, chances for relapse and improves clients’ lifestyle (Osilla,
2009). In addition, the integrated treatment model applies assertive as
one of the guiding principles towards its success in treating the mental
illness and substance use addiction simultaneously. This implies that
health practitioners use assertive outreach and legal measures to ensure
that all persons with the co-occurring disorder attain the necessary
medical care. This is crucial given that some patients have functional
impairment and may not be able to follow the treatment process.
The integrated treatment approach applies multiple psychotherapeutic
modalities, which are indispensable in restoring the sense of self worth
in patients. Given that clients with co-occurring mental illness and
substance use disorders face a lot of stigmas from the members of
society, the application of multiple approaches that address the
medical, moral, and social aspects of the patient is inevitable. The
motivational services offered to the clients enable them to maximize the
utility of treatment and recovery interventions. The motivational aspect
of the recovery process involves different participants the support
groups and family members. The integrated treatment model appreciates
the role of close members of the facility and society at large in
buffering the clients with co-occurring disorders from negative effects.
Participation of different parties in the treatment and recovery process
ensures that the treatment follow up is made, thus reducing the chances
of medication drop out (Osher, 2012). In addition, a properly
implemented model enables clients to participate in the management of
their own disorders. This is a key milestone towards the achievement of
self independence and functional capability. The illness management
training programs offered to clients in the integrated treatment plan
enable them collaborate with the health practitioners and family members
in management of their co-occurring disorders. The training programs
include training on recognition of the early warning signs of relapse to
substance addiction, development of relapse prevention measures,
compliance with medical prescription, and pursuance of personal goals in
life. In regard to this, the integrated treatment model aims at long
term solution by ensuring that clients can take care of their social and
economic affairs. An integrated treatment plan improves the substance
use and depression outcomes over time. Moreover, while assessing the
clinical outcome of an integrated treatment of co-occurring depression
and substance disorders, Lisa (2009) established a positive relationship
between the clients’ participation, early treatment onset, and high
attendance of clients with long term improvement in the treatment of the
co-occurring mental depression and substance used addiction.
Application of medical management in the treatment of co-occurring
disorders:
Medication management is an essential part of treating the co-occurring
mental illness and substance use disorders. Clients suffering from a
combination of substance use addiction and mental illness often
undergo polypharmacy to manage an assortment of disorders simultaneously
(smith, 2012). The large number of drugs coupled with the fact that
some clients with co-occurring disorders suffer from functional
impairment necessitates the application of medication management. This
helps in protecting the client from the risk of abusing drugs and fails
to comply with the prescription. The medication management aids in
detection of negative drug complications that may occur from adverse
drug interactions. An efficient medication management involves the
provision of a printed list of medical description, dosage, and usage.
This helps the patients in appreciating the medical prescription and
observing the time for taking the drugs. The medication management in
cases is a serious mental illness and substance use disorders involve
the use of distinctive devices to help consumers in keeping track of
dosage intervals (Pharm, 2009). In addition, medication management
includes the warnings about the drugs that should not be taken together
with food, potential side effects that the consumer should expect from
consuming the drugs, and the ricks of over- or under-dose. The
advancement of technology has contributed much in enhancing the
effectiveness of medication management. Currently, health care givers
use computer programs to warn them in case they prescribe conflicting
drugs. Additionally, the computer programs help the healthcare
practitioners improve the accuracy in keeping records of consumers and
ease the recovery follow-up.
Success factors in medication management for treatment in co-occurring
disorders:
Medication is one of the key factors that determine the success of
treatment and recovery process of patients suffering from co-occurring
substance use and mental disorders. Medication plays the key role in
prevention of relapse, reduction of symptoms, cravings and enhances
abstinence from addictive drugs. The medication management, on the other
hand, plays a key role in informing the clients on the need and reason
for medication as well as the means of complying with the prescription.
In addition, medication management makes an informed decision about
taking medicine. This is made possible by equipping the consumers with
sufficient information on the benefits of medication and the cost of the
treatment process. Effective medication is one the factors that
determine the success of treatment and recovery from mental and
substance use disorders. While evaluating the role of medication in the
treatment of co-occurring disorders, Blanco, Secade & Nunes (2012)
identified that the administration of selective serotonin reuptake
inhibitors (antidepressant medication) reduces the symptoms of
psychiatric disorders (including mental depression) by 51 %. The
researcher concluded that effective administration of medical regimen is
the foundation success in treatment and recovery process for persons
with co-occurring substance use addiction and mental illness. However,
the administration of drugs alone has been proven to be less effective
compared to a holistic therapy. In addition to drug administration,
holistic therapy appreciates the need for other treatment measures such
as massage, hypnotherapy, and acupuncture.
An effective medication management is significant in the detection and
control of potential side effects. Adverse side effects may result from
negative reactions between the immune system of the consumer and the
prescribed drugs. They elevate the functional impairment and result in
the emergence of new health challenges such allergic reactions and
changes in blood pressure. Early detection of side effects during the
treatment co-occurring disorders help the health practitioners to change
the timing, dosage, and medical drug before adverse effects are out of
hand. Noncompliance with the prescriptions is yet another challenge,
which increases the chances of occurrence of side effects in the
treatment of co-occurring disorders. There are several factors, which
contribute to non-compliance. According to the AG-DHA (2012) apathy
is the main factor that results in non-compliance with medical
prescription among the clients suffering from co-occurring disorders.
Other factors that contribute to lack of adherence to medical
prescription include lack of confidence with the effectiveness of the
medication, issues of interactions between prescribed drugs and
substance use, an assumption of full recovery before the full dosage,
lack of family support, and failure to establish the relationship
between the co-occurring disorders and the prescribed medication.
Medication management plays a vital role in helping the patients
establish a relationship between the co-occurring disorders and the
medication prescribed to them. Some clients attribute the symptoms of
mental health such as hallucination, depression, and fatigue to the
medication (The AG-DHA, 2012). However, interventions through the
medication management can help in enlightening the consumers about the
potential effects of medication before they undertake the medication. In
cases of serious mental illness, apathy may make it difficult to
convince the client that medication is the most appropriate solution.
In addition, the attitude of the family towards the medication plays a
role in determining the clients’ adherence to the prescription. To
this end, the provisions of medication management require that health
care providers should educate both the client and the family members on
the mental health and substance use treatment. This helps the family
members and the consumer to appreciate the need for medication and
adherence to medical prescription. Medication management programs help
in eliminating the perception among the member of a support group that
the drugs prescribed by the health professionals are potentially
addictive.
Persons suffering from co-occurring mental health and substance use
disorders are fond of tapering or even discontinuing medication once the
disorders are stabilized. This exposes them to the risk of relapse
within different durations, which depends on the disorders affecting the
patient. For example, the relapse of symptoms of serious disorders such
as bipolar and psychotic disorders occurs within a year discontinuing
the medication. It is recommended that medication should be continued
for life in case consumer suffers from bipolar and psychotic disorders.
The recommended duration for taking drugs after recovery from non-severe
disorders is six months.
Challenges facing the clients with co-occurring disorders:
The health problem is a considerable challenge to personal development
because it thwarts the efforts of individuals in pursuing their goals in
life. This even worse in case of co-occurring substance use disorders
and mental illness, which lays a double burden to the patient. The
health conditions of persons suffering from co-occurring substance use
disorders and mental illness exposes them to secondary challenges, all
of which affects their lifestyle negatively. Chudzynski (2010) reported
that individuals suffering from co-occurring substance use disorders and
mental disorders face both of the self stigma and stigma from the
members of the society. A feeling of rejection among this population
makes them lose the sense of self worth, self dignity, and hope for the
future. Stigmatization among the people suffering from co-occurring
disorders makes them fit in groups of substance abusers, a situation
that increases the chances for relapse to substance addiction. In
addition, the fragmented treatment model, which are currently dominated
discriminate against the patients suffering from co-occurring mental
illness and substance use disorders. Offering services to one patient at
different locations and by different staff subjects this population into
confusion. This is because the clients get treatment and recovery
reports that are not consistent.
Different researchers in the field of co-occurring disorders established
various challenges among the population of persons suffering from
co-occurring disorders. While comparing the housing first and treatment
first programs for persons suffering from serious mental illness, Tate,
McQuaid, & Granhol (2012) suggested that the population of persons
suffering from co-occurring substance use disorder and mental illness
are hard to reach. This is because these people suffer from many
problems ranging from health, social, and economic challenges. Their
mental problems added to the substance abuse subjects them to an array
of challenges such as victimization, incarceration, and homelessness. At
times, severe disorders make the client violent and difficult to live
with other members of the community. However, in such situations,
application of harm reduction policies with respect to substance use and
consumer choice may be used to stabilize the disorders.
Summary:
This chapter provides an evaluation of the previous research works,
which have addressed the prevalence of co-occurring disorders. The
effectiveness of traditional (including parallel and sequential)
treatment model and the integrated treatment model were evaluated in
enhancing the outcome of treating the co-occurring mental illness and
substance use disorders. Different sources of data such as published
journals and books are suitable in reviewing the previous research works
in the field of co-occurring disorders. Different knowledge gaps exist
regarding the approaches of data collection, sample determination, and
interpretation of findings in the previous research works. Search
engines are some of the reliable sources of published journals, books,
and other published sources of research works.
Previous research works indicate different rates of prevalence of
co-occurring substance use addiction and mental illness. However, the
general trends indicate that the disorders present a significant
challenge in mental health and substance abuse treatment. About 92 % of
patients suffering from mental illness often have the substance use
addiction (Genevieve & Pauline, 2009). Moreover, 84 % of women suffering
from mental illness engage in substance abuse. Additionally, women
suffering from co-occurring disorders have the highest rate of suicide
cases, suicidal in ideation, and incarceration. The researcher has also
identified that 43 % of people suffering from co-occurring disorders are
the youths aged 24 years and bellow. Peer pressure and underdeveloped
brains are the key factors that contribute to the high rate of substance
abuse among the youths with mental illness.
The models available for the treatment of co-occurring mental illness
and substance use disorder have gone through drastic changes. Currently,
the fragmented treatment models (including the parallel and sequential)
dominate in most health centers for treatment of the co-occurring
disorders. The fragmented models for treatment of co-occurring disorders
are characterized by poor treatment outcome, frustration of clients
leading treatment drop out, and high probability of relapse to substance
addiction. The most appropriate alternative available to resolve the
challenges presented by the fragmented treatment models is the
integrating them at the client level. However, the little integration in
a few health institutions has been done at the provider level, thus
providing minimum benefits to the client. In addition to the fragmented
models, other factors that limit the clients’ access to the treatment
include stigma and the discriminating funding schemes.
The transition from the fragmented treatment model to the integrated
treatment mental illness and substance use disorders is highly
encouraged in different research works (Genevieve & Pauline, 2009 and
Blanco, Secade & Nunes, 2012). However, the conviction of the
stakeholders (including the policy makers and health practitioners)
requires a clear identification of the bottlenecks of the current
treatment models and the benefits of integrating the two treatment
settings. Some of the researchers have identified the benefits of
integrated treatment models such as improved treatment outcome, reduces
the cost of treatment, minimized treatment drop out, and better
lifestyle of the client. Different researchers have used varying methods
of data collection, data analysis, and interpretation. However, the
measurement of the effectiveness of the integrated treatment model
requires an effective method of data collection that allows the
efficient follow up of the clients’ treatment and recovery process.
Relying solely on data from the established databases (such as
Epidemiologic Survey on Alcohol and Related Conditions) may not be
sufficient to convince the stakeholders in the health dockets about the
effectiveness of the integrated treatment model in the treatment of
co-occurring disorders Alergria, et al, 2011). To this end, the
qualitative research method was selected to conduct the data collection
exercise using techniques such as observation, interviews, and
administration of PGBWI questionnaires.
The establishment of the benefits of the integrated treatment model is
the suitable means of reducing the challenges that face the consumers
suffering from mental illness and substance use disorders. The
implementation of the integrated treatment models requires that the
stakeholders in the health dockets overcome the barriers to integration
including the separate funding streams, varying treatment philosophies,
limited resources, and administrative barriers. The successful adoption
of the integrated treatment model for treatment of the co-occurring
disorders will benefit both the health care providers and the client.
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