Complexities of Co-Occurring Conditions

United States

Harnessing Services Research to Improve Care for Mental, Substance Use, and Medical/Physical Disorders

Introduction

Many individuals simultaneously suffer from mental illness, problem alcohol and drug use, and other medical or physical disorders, resulting in enormous individual suffering and societal costs. Common comorbidities include mood disorders compounded with substance abuse, chronic pain with depression and/or drug abuse, anxiety disorders with cancer, panic disorder with asthma, hepatitis C with alcohol dependence, and schizophrenia with post-traumatic stress disorder. Such comorbidities may fluctuate across the lifespan in a cyclical pattern of heightened risk, onset, intervention, recovery, and relapse, challenging the utility of the traditional “acute care” model of service delivery for these conditions. Furthermore, the understanding of the combined service needs of persons at risk for developing, or currently suffering from, co-occurring disorders, and the mechanisms by which such needs can be met effectively, is relatively limited. Given these issues surrounding co-occurring conditions, the U.S. Department of Health and Human Services sponsored the conference “Complexities of Co-Occurring Conditions: Harnessing Services Research to Improve Care for Mental, Substance Use, and Medical/Physical Disorders,” a collaborative effort among the National Institutes of Health (National Institute of Mental Health, National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism), Substance Abuse and Mental Health Services Administration, Agency for Healthcare Research and Quality, and Health Resources and Services Administration.

Attended by health services researchers, care providers, administrators, policymakers, and members of the media, the conference showcased theoretical models and research findings on the organization, management, and financing of prevention, treatment, and aftercare services to enhance access, quality, and cost-effectiveness of care for individuals at risk for, or suffering from, co-occurring conditions. Many of these topics were covered in four plenary sessions: Complexities of Co-Occurring Conditions, Service Access and Utilization, Quality and Financing of Co-Occurring Services, and Health Disparities. Fifteen presentations from the plenary sessions are highlighted here.

Plenary Session 1: Complexities of Co-Occurring Conditions

Science and Service: Opening Pathways to Better Mental Health

Richard K. Nakamura, Ph.D.

Dr. Richard Nakamura, deputy director of the National Institute of Mental Health (NIMH), explained that for purposes of the conference, the definition of behavior must be larger than individual behavior, to include the system of behavior through which care is delivered. Dr. Nakamura pointed out that the mission of NIMH is to reduce the burden of mental and behavioral disorders through research on the mind, brain, and behavior, and cited statistics from several World Health Organization surveys showing the extent of the burden. Nakamura also discussed the new understanding of the brain—that our genes specify a general plan with many options. The brain changes its physical structure through behavior and interactions with the environment, integrating nature and nurture, mind and brain, genes and the environment. Nakamura discussed the process of neurogenesis in the adult brain and how this allows new learning throughout life. He also touched on impairments to neurogenesis, such as stress, anxiety, PTSD, depression, and childhood trauma. In conclusion, Nakamura explored the implications for psychotherapy and pharmacotherapy and the development of new outcome models.

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The Co-Occurring Matrix for Mental and Addictions Disorders

Richard K. Ries, M.D.

Dr. Richard Ries, professor of psychiatry at the University of Washington and director of outpatient psychiatry at Harborview Medical Center in Seattle, Washington, covered specifics of the Co-occurring Matrix. The matrix addresses two illnesses and systems—mental health versus addictions and low versus high severities, creating a four-quadrant conceptual framework for systems integration and resource allocation in treating individuals with co-occurring mental and substance abuse disorders. Ries explained several unresolved issues involved with using the matrix and pointed out that to date, no data exists for measuring outcomes of use. Ries also discussed the Harborview Health Services Research Group’s attempt to categorize approximately 6,000 patients into the four categories.

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Co-Occurring Disorders: The “Z-axis”

Richard Saitz, M.D., M.P.H.

Dr. Richard Saitz, of Boston University and Boston Medical Center, discussed just what is meant by the term comorbidity and the confusion it causes for service providers, patients, and families. How do you diagnose comorbidity? What is the primary diagnosis—mental health, substance abuse/addiction, or medical condition? Saitz used several case studies to highlight the complexities this causes in treating an individual with co-occurring conditions. Further, Saitz explored a “Service Coordination by Severity” conceptual framework proposed by SAMSHA and how to expand this framework to integrate medical care, or what Saitz refers to as the "Z axis"—medical severity. Saitz went on to present data on the risks for co-occurring disorders, such as alcohol-related emergency and hospital utilization; medical disorders more common in patients with substance use disorders, psychotic disorders, or both; and comorbidity in a detoxification sample. Saitz concluded his presentation by addressing how mental health/substance abuse comorbidity issues impact the care of chronic medical conditions and by presenting models of care for patients with co-occurring medical, psychiatric, and substance abuse disorders. Models of care included integrated primary care and addiction treatment, integrated medical and alcoholism care, and buprenorphine treatment in primary care.

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Addressing Co-Occurring Conditions: A Provider’s Perspective

Joan E. Zweben, Ph.D.

Dr. Joan Zweben, professor of psychiatry at the University of California, San Francisco, and executive director of the 14th Street Clinic and East Bay Community Recovery Project, presented a provider’s perspective to addressing co-occurring conditions. She outlined many of the services provided by the clinic, but enumerated the many obstacles to providing thorough, quality care. These obstacles include poor policy statements and poor communication between government entities, resulting in conflicting expectations and requirements between programs. Zweben called for policy statements to be collaborative (i.e., interagency) and to outline expectations for treating persons with Co-Occurring Disorders. Policies should also clearly identify the impropriety of excluding persons with Co-Occurring Disorders from either treatment systems or other service systems. Zweben also examined issues of training and licensing professional and nonprofessional care providers. She concluded by highlighting the need for a universal charting system to allow consistent data collection.

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Plenary Session 2: Service Access and Utilization

Alcohol Use Disorders and Co-Occurring Conditions

Ting-Kai Li, M.D.

Dr. Ting-Kai Li, director of the National Institute on Alcohol Abuse and Alcoholism, presented an overview of alcohol use disorders and co-occurring conditions, the onset of alcohol use and alcohol use disorders, and screening and brief interventions. Currently, 18 million Americans are suffering from alcohol use or dependence (100,000 die annually) and alcohol problems in the U.S. cost an estimated $185 billion per year. Li outlined some of the reinforcing effects, aversive effects, and peer/cultural influences that encourage or do not encourage people to drink, and covered the rate of co-occurrence of alcohol dependence with nicotine dependence, other drug dependencies, mood and anxiety disorders, and personality disorders. Li then presented information on two important public health issues—age of onset of alcohol use and family history of alcoholism and their influences on lifetime alcohol dependence. Li also discussed age of onset for cannabis use disorders, tobacco dependence, and major depression; a developmental perspective on age of onset of brain disorders (ADHD, antisocial behavior, obsessive compulsive disorders, eating disorders, panic disorders, bipolar, etc.); screening protocols for high-risk drinking; and counseling interventions.

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Preventing Co-Occurring Disorders: Prospects and Opportunities

J. David Hawkins, Ph.D.

Dr. David Hawkins, director of the Social Development Research Group at the University of Washington, discussed the prevention of co-occurring disorders. He explained that such prevention requires the identification of malleable risk and protective factors that predict comorbidity. Risk factors occur in a number of domains—the individual, the community, the family, and the school—and predict a broad set of behavior and health outcomes in young adults. Some of these outcomes are substance abuse, teen pregnancy, violence, depression and anxiety, and school drop-out. Hawkins segued into a discussion of protective and promotive factors that appear to buffer exposure to risk and reduce the likelihood of health and behavior problems. Some of these factors are individual characteristics while others exist in the neighborhood, school, family, and peer group. The overarching question was, “Can predictors of comorbidity be identified in early adolescence, and if so, would addressing these predictors prevent comorbid disorders in early adolescence? Hawkins presented data on the Seattle Social Development Project, a longitudinal study of the etiology of prosocial and antisocial behaviors in 808 5th grade students that examined four treatment designs: full treatment, late treatment, parent-training only, and a control sample. Hawkins concluded by outlining intervention strategies and their results on bonding to school, violent delinquent behavior, heavy alcohol use, high school graduation, and depressive symptomatology.

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Complexities of Co-Occurring Disorders: State Agency Perspective

Renata J. Henry, M.Ed.

Dr. Renata Henry, director of the Division of Substance Abuse and Mental Health in the Delaware Department of Health and Social Services, spoke about the development of a state infrastructure of services and systems to treat individuals with co-occurring disorders. Henry discussed the barriers and challenges that exist to creating a truly integrated system, some of which include the existence of separate and uncoordinated state mental health and substance abuse systems, disparate insurance coverage, categorical funding streams, few staff bridges between programs, and little connection between providers and programs. She also presented solutions that Delaware has introduced for breaking some of these barriers. In addition, Henry addressed action items at the administrative, Federal, and research levels to improve services for individuals with co-occurring disorders.

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Access to Best Practices for Co-Occurring Disorders: Research and Practice Partnerships

Constance Weisner, Dr.P.H., M.S.W.

Dr. Constance Weisner, professor of psychiatry at the University of California at San Francisco and investigator in the Division of Research at Kaiser Permanente Medical Systems, spoke about the importance of practice—research collaborations and studying access to services when treating co-occurring disorders. She presented a framework for broadening the research focus—posing new and different research questions, moving away from the traditional paradigm of reaching the next step in a research agenda, collaborating with clinicians, and putting far more emphasis on the implementation process. Weisner also covered the importance of access to screening, assessment, and integrated services. She presented data from four cities in California on adolescent chemical dependency (CD), psychiatric conditions of adolescents entering CD treatment, and characteristics of adolescents with suicidal behavior diagnoses. Additional data also addressed whether psychiatric services and medical services are related to outcome in treating co-occurring disorders.

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Plenary Session 3: Quality and Financing of Co-Occurring Services

Advancing Excellence in Health Care: Complexities of Co-Occurring Conditions

Helen Burstin, M.D., M.P.H.

Dr. Helen Burstin, director of the Center for Primary Care, Prevention, and Clinical Partnerships at the Agency for Healthcare Research and Quality (AHRQ), stressed that AHRQ’s research is different in that it is more patient-centered, as opposed to disease-specific, and that AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. The AHRQ currently sponsors 13 evidence-based practice centers that review scientific literature on clinical, behavioral, and organization and financing topics; conducts research on the methodologies and effectiveness of their implementation; and requires nomination by an organization that will use the reports to support quality improvement. Burstin also focused on AHRQ’s goal to improve the quality of healthcare and reduce disparities in healthcare delivery, citing statistics that address limitations. She also discussed AHRQ’s initiatives to focus on mental health and substance abuse issues, such as the prevalence of chronic conditions in adults, depression and healthcare utilization, supporting practice-based research networks, and working with the U.S. Preventive Services Task Force. Burstin concluded by addressing opportunities and challenges, particularly what she calls the “quality chasm” between where we are and where we want to be in terms of implementation, innovation, health information technology, diffusion, adoption, and translating research into practice.

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Measuring What Counts—AND—Making it Count for Quality

Constance Horgan, Sc.D.

Dr. Constance Horgan, of Brandeis University and director of the Schneider Center for Behavioral Health, began by asking if we can measure what counts and how we can make it count for driving quality. Her presentation covered the background on quality and performance measurement and using performance measures in the role of stakeholders, particularly purchasers. Performance measurement is a tool to evaluate a managed care plan, health plan or program, hospital, or healthcare practitioner, and implies that the entity providing healthcare is responsible, can be identified and held accountable, and has control over the aspect of care being evaluated. She presented information on how we are doing in terms of providing medical care—selected behavioral health initiatives, particularly the Washington Circle; service facilities where adults with co-occurring disorders are being seen; and challenges to performance measures for co-occurring conditions.

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Five Dimensions of Quality

David Rosenbloom, Ph.D.

Dr. David Rosenbloom, director of Join Together and the NIAAA Center to Prevent Alcohol-Related Problems Among Young People, addressed how to define quality, how to measure it, identify, and remove barriers to it, and how to reward better results. He explored these issues by presenting five dimensions of quality—patient satisfaction, information and emotional support, amenities/convenience, decisionmaking efficiency, and outcomes—and suggested measuring these dimensions, perhaps through a patient-feedback system. Rosenbloom also enumerated specific outcomes to measure, such as home care, cancer care, and functional improvement in rehabilitation. He concluded by addressing components of quality, measuring these components, and suggested barriers to quality.

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Paying for Performance—Sounds Good…. But What Performance Are WE Paying For?

Nancy Wolff, Ph.D.

Dr. Nancy Wolff, Director of the Center for Mental Health Services and Criminal Justice Research in the Institute for Healthcare Policy and Aging Research, offered a more conceptual perspective of paying for performance in healthcare services. She focused on different levels of performance—facility, client, and society—and on obtaining the type of services needed. Wolff recommended targeted efficiency so money will have its most powerful effect and the return on the investment dollar will be higher. This can be achieved by evaluating cost distribution and areas of need and asking what is leading spending—funding or need? Wolff ended her presentation by exploring the connection between immediate and sustained client outcomes, client and social outcomes, and the notion of rewarding performance.

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Plenary Session 4: Health Disparities

Understanding & Treating Co-Occurring Conditions: A Major Research Priority for NIDA

Nora D. Volkow, M.D.

Dr. Nora Volkow, director of the National Institute on Drug Abuse, stressed that drug addiction is a complex interplay of the chronic effects of drug administration, biological factors (including genetics), and environmental factors. She discussed three of NIDA’s current priority areas: (1) prevention research aimed at children and adolescents, which includes areas of genetics, development, environment, and comorbidity; (2) treatment development, utilization of treatment strategies, and elimination of translational bottlenecks between publishing important research findings and testing treatments in clinical trials; and (3) HIV/AIDS research and drug addiction as it relates to the HIV/AIDS epidemic. Volkow explained that drug addiction is a developmental disease that starts in early adolescence. NIDA aims to examine whether drug addiction affects the adolescent brain differently than an adult brain, and learn why addiction begins in the early stages of development. Volkow also highlighted data on the prevalence of comorbidity between smoking and certain mental disorders and addictions, and how comorbidity has directly influenced the field of health services research and treatment.

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A Socio Cultural Framework for Mental Health and Substance Abuse Service Disparities Research with Multicultural Populations

Margarita Alegria, Ph.D.

Dr. Margarita Alegria, professor of psychiatry at Harvard University and director of The Center of Multicultural Mental Health Research at Cambridge Hospital, presented a sociocultural framework of mental health and substance abuse service disparities with multicultural populations. Racial and ethnic minorities have less access to substance abuse and mental health services, are less likely to receive needed care, and are more likely to receive poor quality care when needed. There are currently no models to facilitate the understanding of mental health and substance abuse disparities for ethnic and racial minorities. Alegria’s team expanded the IOM definition of service disparities by postulating six, rather than two, sources of service disparities and by including access-related factors, which were discussed at length. Alegria presented information on how the use of specialty care by poor Latinos is effected by poverty and minority status and the percentage of Medicaid patients receiving various types of treatment for depression 6 months after diagnosis (by ethnicity). Alegria also touched on healthcare policies and regulations at the state and Federal levels, healthcare market forces, community systems, provider/clinician stereotyping, and patient- and family-level factors of healthcare disparities.

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Drug-Involved Women and HIV: Co-Occurring Risk Factors

Nabila El-Bassel, Ph.D.

Dr. Nabila El-Bassel, professor at Columbia University and director of The Center for Intervention and Prevention Research on HIV and Drug Abuse, presented information on incidence disparities in HIV/AIDS among women in the United States; co-occurring risk factors for HIV among African-American and Hispanic drug-involved women; and implications for HIV prevention, intervention, and services for drug-involved women. Her data included new AIDS cases and rates among women by race/ethnicity (White, Black, Hispanic, Asian/Pacific Islander, American Indian/Alaska Native); prevalence of HIV/AIDS among women in the U.S.; and AIDS incidence by region, race/ethnicity, and exposure category. Some risk factors El-Bassel covered were ontogenetic and interpersonal factors including history of childhood sexual abuse, post-traumatic stress disorder, drug use, and intimate partner violence. Structural factors involved lack of access and availability to women-specific treatment and services, and macro factors addressed economic and social power imbalances, attitudes toward drug-involved women, and sexual gender roles.

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