Academic journal article Alcohol Research

Integrating Care for People with Co-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions

Academic journal article Alcohol Research

Integrating Care for People with Co-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions

Article excerpt

It is widely recognized that the majority of patients with alcohol use problems also suffer from co-occurring mental health and medical problems. Co-occurring disorders (CODs) complicate the treatment process and, in many cases, contribute to poorer outcomes (Drake et al. 1996; Rosenthal and Westreich 1999) as well as higher service utilization and costs over time (Curran et al. 2008; Lennox et al. 1993). In the past, clinicians within each treatment setting--alcohol treatment, mental health, and general medicine--frequently treated COD patients as they would patients with only one of these disorders; however, such treatment is not well suited to the special needs of patients with CODs (Rosenthal and Westreich 1999). Extensive research has documented the need to treat all conditions from which patients suffer and has identified many key components of the best practices for achieving this goal (Goldman et al. 2000; Minkoff 1991; Minkoff and Ajilore 1998; Osher 1996). Moreover, a growing body of research suggests that integrated approaches to treatment may improve the outcomes of patients with alcohol problems (Craig et al. 2008; Drake et al. 2004, 2008; Goldman et al. 2000; Minkoff and Ajilore 1998; Osher 1996). Although optimally integrated care still is the exception in most treatment settings, interest in this approach is mounting, and many programs are attempting to incorporate integrated models of care.

This articles draws from the framework established in the Institute of Medicine (IOM) (2006) report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, and other literature to consider the state of integrated care for people with alcohol problems and CODs. It examines how integrated approaches can make treatment more attractive to patients and contribute to higher retention rates and better outcomes, and discusses strategies and mechanisms that facilitate greater integration. it also considers barriers that impede optimal coordination of care for CODs, including organizational fragmentation; stigma; financing mechanisms; and the complex issues of confidentiality, patient safety, and the free flow of information necessary to implement integrated treatment approaches. Throughout the article, the term "disorder" refers to alcohol or other drug (AOD) use problems that meet the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for abuse or dependence. The term "unhealthy use" describes less severe but problematical AOD use. The term "problems" encompasses the entire spectrum of severity.

SCOPE OF THE PROBLEM

Prevalence of Co-Occurring AOD and Mental Health Problems

The high prevalence of co-occurring AOD problems and mental health conditions has been well documented in the addiction and psychiatric literatures. There are several excellent reviews of the epidemiologic research (Cornelius et al. 2003; Kessler 2004), and many studies of clinical samples (Compton et al. 2000; Flynn et al. 1996; Jainchill 1994; Sacks et al. 1997), as well as large national (Grant et al. 2004; Hasin et al. 2007; Kessler et al. 2005) and international (Kessler et al. 2007) population surveys, have been published. Lifetime prevalence of CODs among those seeking treatment for AOD disorders has been estimated at anywhere from one-quarter to well over one-half. For example, the National Comorbidity Survey, a general population survey of adults, found that 51.4 percent of those surveyed with a lifetime AOD disorder also reported a lifetime mental health disorder, whereas 50.9 percent of those with a mental health disorder reported having had an AOD disorder (Kessler 2004). The co-occurrence of AOD problems with mood and anxiety disorders is especially high. In a general population sample, the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that of those with at least one AOD disorder, 20 percent suffered from a mood disorder and 18 percent from an anxiety disorder in the same period. …

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