Integrating Treatment for People with Co-Occurring Mental Health and Substance Abuse Disorders in Public Systems of Care

Research has shown that the most effective treatment for people with co-occurring mental health (MH) and substance abuse (SA) disorders involves integrated care for both conditions. However, systemic and clinical barriers often block this integration. Historically, treatment for these conditions has been delivered by separate provider communities and has been financed separately. In recent years, successful efforts have been made to overcome these barriers.

A RAND study led by psychologist Audrey Burnam examined these efforts. The analysis reviewed recent progress, identified challenges, and pointed to promising directions for future care and financing arrangements. Researchers reviewed the clinical literature and synthesized results from interviews with directors of MH and SA agencies in 23 states. These data suggest that progress is being made in two key areas:

• Integrated treatment models. In the past decade, new treatment models have emerged that combine MH and SA care at the client level. The most common approach is integrated dual disorders treatment (IDDT), which provides intensive and comprehensive services for severe MH and SA disorders simultaneously. Numerous studies support the effectiveness of IDDT. Key questions for broader use of this approach are (1) what level of service intensity is required for IDDT to be effective and (2) whether the target population should include people with less-severe illness, for whom a less intensive approach might work as effectively.
• Innovative financing arrangements. To overcome obstacles posed by separate funding streams, created largely by federal Medicaid rules and by categorical block grants, some states have developed financing strategies that can support services for co-occurring disorders integrated through the provider agency. A few states have undertaken broader Medicaid reforms that operate through contracts with managed-care organizations to create more flexibility to fund both MH and SA treatment services. A major challenge in this area is streamlining the stovepiped administrative apparatus that regulates various aspects of MH and SA services, such as licensing and quality standards.

The study points to three promising avenues for further improvement:

• Clinical models that emphasize service delivery in a single setting. For example, developing the capacity of the SA treatment system to deliver MH care, or vice versa, could have large payoffs.
• State-level reforms. Streamlined program administration and greater state commitment to supporting integrated models of care across populations and settings hold promise for improving treatment for people with co-occurring disorders.
• Federal policy changes. Policy changes can create opportunities for states to develop and sustain integrated models of care for co-occurring disorders within the fiscal and regulatory environment of the SA treatment system. For example, expanding federal block-grant or Medicaid funding to pay for psychiatric medications and for MH assessment and medication management for people in treatment for severe SA disorders is a promising investment. However, further analysis is needed to assess the costs and benefits of such strategies.