Critical Issues - Program / Policy Issues

From: New Directions for Mental Health Services, No. 50, Summer 1991

Program Components of a Comprehensive Integrated Care System for Seriously Mentally Ill Patients with Substance Disorders

Kenneth Minkoff


During the last two decades, deinstitutionalization has been increasingly associated with the emergence of large numbers of individuals with concomitant substance disorders and severe, chronic psychiatric disorders. The breadth of this problem has been documented by numerous studies measuring the prevalence of substance abuse and substance dependence among chronically mentally ill patients. These studies have indicated a rate of substance abuse¾ variously defined and measured¾ of between 32 and 85 percent, and prevalence of substance dependence¾ again variously defined and measured¾ of between 15 and 40 percent (Pepper and others, 1981; Schwartz and Goldfinger, 1981; Alterman, 1985; Safer, 1987; Caton, Gralnick, Bender, and Simon, 1989; Drake, Osher, and Wallach, 1989.) Similarly ECA studies have demonstrated a markedly increased prevalence of severe psychiatric disorders, such as schizophrenia and bipolar disorder, among patients with substance dependence diagnosis (Regler and others, 1990).

Such large numbers of dual diagnosis patients have clearly created significant difficulties not only for individual clinicians and programs, but for entire systems of care¾ both for the addiction system and for the mental health system. Bachrach (1986-87) has written that these patients are frequently "system misfits"; they do not readily conform to established expectations within each system for obtaining access to care. Addiction programs and addiction clinicians are often ill-equipped to deal with addicted patients who present with psychotic symptoms and/or who require prescription of psychotropic medication, and mental health programs are often similarly ill-equipped to treat patients who require an abstinent environment an/or an intensive addiction recovery support system in which to address substance abuse or dependence. Development of integrated or hybrid programs has been proposed as a solution to this dilemma (Ridgely, Osher, and Talbott, 1987; Osher and Kofoed, 1989; Sciacca, 1987), but even where such programs exist they cannot adequately respond to either the diversity of dual diagnosis patients or the sheer numbers of them within any given care system.

The literature on treatment of dual diagnosis patients has described specific clinical techniques (Koefed, Kanla, Walsh, and Atkinson, 1986; Evans and Sullivan, 1990; Osher and Kofoed, 1989) and individual hybrid treatment programs (Ridgely, Osher, and Talbott, 1987, Minkoff, 1989), but with rare exceptions (Drake and others, in this volume), it has not addressed the more complex problem of how to design a comprehensive care system to meet the needs of the dual diagnosis population as a whole. The purpose of this chapter is (1) to define specific issues that must be addressed in a comprehensive care system, (2) to describe an integrated theoretical framework for understanding dual diagnosis, and (3) to use this framework to develop a model system of care.

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