The combination of substance use disorders and mental illness is a common clinical problem – and a serious public health concern. The problem is widespread. At least one-third of people with anxiety and depression – and between half and two-thirds of people with more serious mental illnesses such as schizophrenia, bipolar disorder, and severe depression – have a problem with alcohol, illicit drugs, or both. When you include tobacco, this brings the figure up to nearly about 80 percent. The most commonly misused substances are tobacco, alcohol, cannabis, and cocaine – although opioid use is increasing in this population.
Co-Occurring Disorders Cause Poor Outcomes
In addition to increased mortality, people with co-occurring disorders experience worse psychiatric symptoms, less engagement in treatment, challenges functioning in everyday life, higher rates of suicidal and violent behavior, legal problems, homelessness, and significant physical health problems. They also experience more frequent intensive health services use, with more emergency department visits and longer inpatient hospital admissions.
Clearly, co-occurring disorders present significant challenges for the affected people, their families, individual clinicians, treatment programs, and the larger healthcare system. Fortunately, the past several decades have seen growing evidence for treatment approaches that work.
Treating Co-Occurring Disorders
At one time, mental health practitioners believed that addiction had to be treated before mental illness could be addressed and vice-versa. The working assumption was often that the substance use drove psychiatric symptoms, which would remit once abstinence was achieved. In turn, addiction treatment providers assumed that people could not benefit from treatment of substance misuse unless their psychiatric symptoms had been stabilized. The wisdom of this mindset has since been soundly refuted.
While it is often difficult to figure out which came first – addiction or psychiatric symptoms – solving the “chicken-and-egg” puzzle is not necessary to effectively treat co-occurring disorders. We now know that treating both addiction and psychiatric illness simultaneously increases the chances that both will improve.
New York State Initiatives
In 2007, OMH convened a joint task force with other state agencies to improve the prevention and management of co-occurring disorders throughout the state. This helped spur multiple initiatives, some of which are described here. Our partners include the Office of Alcohol and Substance Abuse Services (OASAS) and the Department of Health (DOH).
To promote Integrated Dual Disorder Treatment (IDDT) in all mental health settings across the state and strengthen the skills of clinicians in these settings, the Center for Practice Innovations (CPI) has an online training and implementation support initiative called Focus on Integrated Treatment (FIT). In response to recommendations from the joint task force, FIT created 39 online training modules that are available for free with continuing education to licensed behavioral healthcare practitioners throughout the state. FIT also provides ongoing implementation support to promote state-wide dissemination of IDDT.
In 2006, OMH created a program to provide comprehensive, recovery-oriented services for people with serious mental illness called Personalized Recovery Oriented Services (PROS). In addition to other evidence-based interventions including supported employment services, individual psychotherapy, wellness self-management, family psychoeducation, and psychiatric care, PROS offers IDDT to all participants. PROS program clinicians are trained through the FIT modules and can participate in ongoing FIT learning collaboratives.
Assertive Community Treatment (ACT) is considered the highest level of outpatient services available for people with serious mental illness in New York State, and has demonstrated efficacy for improving outcomes among the most difficult-to-engage people. All ACT teams must have a substance use specialist and the capacity to provide IDDT, and have access to CPI training, including FIT. In addition, 10 new ACT teams have been funded by OMH to serve homeless people in New York City, in partnership with the City Department of Health and Mental Hygiene and Department of Homeless Services. These new teams will receive extra training and support in opioid overdose prevention and medication-assisted treatment.
In order to make integrated behavioral health and primary care services available in more settings, OMH has recently partnered with OASAS and DOH to bring about the necessary statutory and regulatory changes to approve Integrated Outpatient Clinic Services (IOS). There were 71 approved IOS sites across the state as of the end of 2017. In addition, New York State is in the process of creating a stream-lined single license. This will allow healthcare organizations to offer mental health, substance use, and medical services under a single license, through a single application process, supported by a single set of rate codes in an integrated setting without duplicative oversight from multiple agencies.
Another recent partnership between OMH and OASAS includes the Dual Recovery Coordinator (DRC) Demonstration Project, which funds 12 DRCs in 14 counties and New York City. Within their counties, DRC coordinators work to develop more seamless and integrated systems of care through training, technical assistance, and infrastructure development.
Recently, New York was one of only eight states selected to participate in a two-year demonstration project to develop new Certified Community Behavioral Health Clinics (CCBHCs). CCBHCs will provide “no wrong door” access to services, treating people with mental illnesses and substance use disorders with a fully integrated approach, while also addressing physical health by providing primary care. The 13 CCBHC sites across the state will provide crisis mental health services; screening, assessment, and diagnosis including risk management; patient-centered treatment planning; outpatient mental health and substance use services; primary care screening and monitoring; targeted case-management; psychiatric rehabilitation services; peer support, counseling services, and family support services; services for members of the armed services and veterans; and connections with other providers and systems (such as criminal justice, foster care, child welfare, education, primary care, hospitals). In addition, all CCBHCs are required to obtain approval for IOS, which will enhance IDDT capacity.
Managed Care for Medicaid
All of this work is being coordinated in the context of comprehensive transformation of behavioral health services in New York State, a cornerstone of which is a complete transition to managed care for all Medicaid-funded behavioral health services. In 2015, New York State moved almost all mental health and substance use treatment services into the Medicaid mainstream managed care benefit package.
New York State also began offering a specialized managed care program called a Health and Recovery Plan (HARP). A HARP is a fully integrated benefit package that manages physical health, mental health, and substance use services in an integrated way for adults with significant behavioral health needs — such as mental health or substance use. HARPs must be qualified by New York State and must have specialized expertise, tools, and protocols that are not part of most medical plans. There are currently more than 100,000 people with a serious mental illness, substance use disorder, or both, in the HARP program.
Central to HARPs are Behavioral Health Home and Community Based Services (BH HCBS). Assessment for BH HCBS eligibility evaluates needs related to mental health, substance use, and physical health risk factors. BH HCBS can be used to support people with developing and strengthening skills related to self-advocacy, stress reduction, medication adherence, shared decision-making, healthy living, and disease management. This integration within payment and service coordination models presents an important opportunity to promote the IDDT approach for managing co-occurring disorders.
OMH knows that people struggling with both mental illness and addiction need access to evidence-based, person-centered, and integrated services. When these services are available and high quality, outcomes improve, people recover, and lives are saved. We still have work to do, but recent initiatives in the context of systems transformation is giving New Yorkers with co-occurring disorders and their loved ones more reason for hope.
For more information on the co-occurring disorders task force, visit: https://www.oasas.ny.gov/pio/collaborate/documents/CODTFReport.pdf.
Sources of research for this article include Manseau and Bogenschutz, Substance Use Disorders and Schizophrenia, Focus, 2016.