Report urges integration of concurrent disorder services
“This admission, that admission, this specialist, that specialist, but nobody’s really doing anything, nothing’s really getting done, just a whole bunch of appointments going nowhere.”
THIS KAFKA-ESQUE SITUATION MAY SOUND LIKE A COMEDY OF errors–but the comment is no joke. This type of experience, related by consumers of mental health and addiction services in focus groups across the country, was part of the impetus behind the creation of the Best Practices: Concurrent Mental Health and Substance Use Disorders document.
Health Canada, Canada’s Drug Strategy (CDS) and the Centre for Addiction and Mental Health (CAMH) released the document late last year. It is a tool to steer practice, help integrate services and, hopefully, keep clients with co-occurring mental health and substance use problems from falling through the cracks.
“We view it as a living document,” says Cathy Airth, acting director of CDS. “This is the sum of the knowledge we have to date, and we hope it gets maximum visibility in the service delivery area.”
The need for a synthesis of research and recommendations for screening, assessment, treatment and support was clear. A recent Ontario study found that 55 per cent of people with an alcohol dependency diagnosis also had a mental health diagnosis. Separate initiatives across Canada identified individuals with concurrent disorders as a priority population. Still, many treatment models have addiction and mental health services working in isolation and often from competing perspectives.
One of the document’s main recommendations is that people seeking help from mental health and/or addiction services be screened for co-occurring disorders. Approaches can be as simple as asking a few questions based on an index of suspicion. Higher-level techniques may use more detailed, codified scales and indexes.
Wayne Skinner, clinical director of the Concurrent Disorders Program at CAMH, says the existence of concurrent disorders should be thought of as the rule, rather than the exception. “We need to have it as our assumption that clients have a very high likelihood of having problems in both mental health and addiction domains.”
Clinicians are encouraged to see assessment as an ongoing process that will take time. This step is critical in sorting out what is called the “chicken and egg” problem of distinguishing co-occurring disorders.
Linda Sibley-Bowers, executive director of Alcohol and Drug Services of Thames Valley in London, Ontario, is pleased to see the inclusive and progressive definitions of integrated treatment. “New in this document is the notion that you can treat concurrent disorders in a parallel way, a chronological way or a concurrent way–and they’re all OK. If you have a substance use problem and an eating disorder, this document recognizes that you might have to focus on the eating disorder first. I see that as an evolution.”
Skinner sees the regionalization of addiction and mental health services in some provinces as a promising development, putting both services in the same domain. In British Columbia, for example, addiction treatment services are back in the province’s health department, after years in another portfolio. “That puts mental health and addictions together into one division,” says Dr. John Anderson, medical consultant for the Mental Health and Addiction Division, B.C. Ministry of Health. “That sends a clear message that centrally, we see the two areas as related.”
It is still early for most provinces to have specific plans to integrate treatment, but Skinner says that many jurisdictions are beginning to embrace the idea, with a high level of interest in training and skill building. B.C. has already begun spreading the word. “We have facilitated dissemination to health regions and also had Brian Rush from CAMH (project team leader for the document) out here to Victoria to do a one-day workshop,” says Anderson.
Sibley-Bowers says that London has hosted a series of free seminars about concurrent disorders for clinicians. She expects the document will be discussed with the local District Health Council, where plans for system-wide integration will begin.
Dr. John Campbell, senior co-ordinator of Adult Mental Health Programs, Halifax Department of Health, says Nova Scotia recognizes the issue, but so far, most activity has been ad hoc and local.
Some point out that the document raises more questions–such as how to deal with specific populations like the elderly or people with special needs. But Skinner says it’s a work in progress. “Sometimes people want to do things, but they get stalled because they don’t know how to shape new practice. I think there is some energy around this. It doesn’t answer all the questions, but it does help people move forward.”
Best Practices: Concurrent Mental Health and Substance Use Disorders has been well received; but there may be one sticking point for some clinicians. The report defines concurrent disorders based on the DSM-IV definition, which uses a medical model that researchers worry may be out of harmony with current addiction treatment methodology.
“In most provinces, the service delivery model for substance use problems was traditionally a sort of non-medical, 12-step model,” says Dr. John Campbell, senior co-ordinator of Adult Mental Health Programs, Halifax Department of Health. “This is changing, but there are still some major philosophical differences.”
“We tend to have a more client-centred approach–asking clients to discuss what their condition means to them,” says Linda Sibley-Bowers, executive director of Alcohol and Drug Services of Thames Valley.
But Sibley-Bowers sees the DSM-IV definition as a communication tool rather than a power transfer. “I think (project leader) Brian Rush was very clear that it’s not about handing over treatment to the medical community. The DSM definition is clear, it is concise and it is an opportunity to professionalize our understanding of community-based help. It allows us to have a common language.”
COPYRIGHT 2002 Centre for Addiction and Mental Health
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