PRESIDENT’S NEW FREEDOM COMMISSION ON MENTAL HEALTH

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Related Story

Related Story in New York State Psychiatric Association Bulletin Spring 2003 

Richard N. Rosenthal, M.D.

President, American Academy of Addiction Psychiatry

Professor of Clinical Psychiatry, Columbia University

Chairman, Department of Psychiatry,

St. Luke's Roosevelt Hospital Center, NY

The American Academy of Addiction Psychiatry, is a professional membership organization with approximately 1,000 members in the United States and around the world. It was founded to:

• Promote accessibility to highest quality treatment for all who need it

• Promote excellence in clinical practice in addiction psychiatry

• Educate the public and influence public policy regarding addictive illness

• Provide continuing education for addiction professionals

• Disseminate new information in the field of addiction psychiatry, and

• Encourage research on the etiology, prevention, identification and treatment of the addictions.

Every state in the union and most academic, research and addiction service delivery organizations are represented in our membership. This nationwide representation allows for efficient access to leaders in the field who are able to rapidly provide and disseminate information, deliver expert testimony, and provide grassroots support to programs. Many consultants to federal agencies, including the preparers of the draft review documents for the Co-occurring Disorders Subcommittee (Minkoff, Ziedonis), are AAAP members.

Thank you for the opportunity to provide testimony. First, we wish to publicly acknowledge our strong support for the work of the Commission and our special appreciation for their recognition of the importance of considering the critical needs of those with co-occurring disorders. We single out for special mention Dr. Rodolfo Arredondo's career-long support of viewing the needs of the "whole person" and his stalwart advocacy for increasing substance abuse education.

What are some of the unmet needs? What are our specific Policy recommendations?

We want to acknowledge the growing body of evidence that there are clinical interventions and programs that work for people with co-occurring disorders, and that there are identifiable principles of successful treatment that are applicable in many settings and systems.

In elucidating the dramatic under-diagnosis and under-treatment of persons with co-occurring disorders and the effectiveness of integrated treatments, the Co-occurring Disorders Subcommittee of the President's New Freedom Commission on Mental Health has made explicit the damaging effects of a system with disparate training, regulatory, and funding support for mental illness and substance use disorders.

We applaud the Subcommittee's policy recommendation that all health training programs receiving DHHS funding must include co-occurring substance abuse and mental disorders in curriculum design; however, this will mostly effect future clinicians. The sub-committee's initial policy recommendation is that federally-funded programs should include co-occurring disorders in program design, standards development, outcomes monitoring, and quality indicators. This will not occur without proper cross-training of practicing clinicians about mental health and addiction screening and treatment.

From our experience as leaders in psychiatry trained in addictions treatment and research, we believe there is a need to increase the focus on substance use disorders and those with psychiatric and medical problems associated with the use/abuse of substances. Clearly, we support the need for proper psychiatric assessment among addicted patients and the need for education about epidemiology, identification and treatment of dual disorders among all mental health and addiction providers.  We further strongly support the policy recommendation establishing a visible focus of authority and responsibility to coordinate existing SAMHSA co-occurring disorder-related activities and interagency linkage.

As leading clinical researchers in co-occurring disorders, we support the need for a federal research initiative to increase interagency collaboration in the development of co-occurring disorder research proposals, including supporting co-occurring disorders-focused new investigator and other research career awards. However, we are concerned that an NIH Office of Co-occurring Disorders Research may add an extra layer which could lead to less, not more co-occurring disorders research in existing institutes, who then might be less inclined to do it themselves. Efforts aimed toward the current institutes might be preferable.

What can we do to help?

We are looking for opportunities to access and utilize the expertise of the membership of the American Academy of Addiction Psychiatry in achieving the goals of this Commission and to assure that those with substance use disorders are included. We are pleased to learn that our views and those of the Co-Occurring Disorders Subcommittee are convergent. Solutions to the difficult issues of treating patients with co-occurring disorders can only be found and put into practice if the best minds from the public and private sectors truly collaborate.

Because we are mental-health professionals trained in addiction, areas where AAAP could be of specific service to the mission of this Committee are:

1. Assisting in reaching consensus definitions of "co-occurring disorders" and "integrated co-occurring disorder treatment," and developing specific, measurable performance standards.

2. Using our experience in training and access to the highest-level evidence-based research and practice to assist in curriculum development for and training of clinicians, especially at the state level (cf, Minkoff*), where AAAP has a track record.

3. Using our unique qualifications to pursue in greater depth the psychopharmacologic aspects of treating co-occurring disorders -- an area that is under-addressed in the current report.

* Minkoff, K. New Freedom Commission Draft Issues Report Co-Occurring Disorders Part II: Overview Of System Change Strategies, 2002, page 2.

Other recommendations of the American Academy of Addiction Psychiatry that the Subcommittee on Co-Occurring Disorders should focus upon:

1. The extremely high comorbidity of substance disorders and mental disorders with HIV and Hepatitis C (as well as other medical illnesses like diabetes, hypertension, etc.) with an emphasis on the poor outcomes that occur when patients receive inadequate treatment for any of these problems.

2. The lack of education for health professionals in each of these areas (medicine, psychiatry and substance abuse) in how to assess and treat comorbid disorders and the problems with access to care.

3. The need for continuing education and training for addiction specialists; we hope to work with you to meet these critical manpower needs upon which the future of addiction treatment rests.

Individuals with co-occurring psychiatric and substance-related disorders experience persistent and recurrent difficulties, which can interfere with every aspect of their lives. These individuals also have a high incidence of medical comorbidity and their clinical course is associated with higher costs and poorer outcomes. In almost all psychiatric and addiction settings, people with co-occurring disorders appear with sufficient frequency that their presence must be anticipated at every of level of care. Settings that serve people with severe mental illness are likely to have a majority of the people seeking care with co-occurring disorders. These individuals are poorly served by systems where treatment for co-occurring disorders is provided in separate settings, with a lack of integration and continuity, and insufficient availability of appropriate programs.

AAAP recommends that in every system of care the following core principles form the basis of a comprehensive, continuous, integrated system for individuals with co-occurring psychiatric and substance-related disorders:

Welcoming: The goal is to insure that each clinical contact is welcoming, empathic, hopeful, culturally sensitive, and makes an effort to engage individuals who may be unwilling to accept or participate in recommended services, or who do not fit into available program models.

Accessibility: Twenty-four hour crisis intervention services should be available to provide assessment and intervention for both psychiatric and substance-use disorders. Barriers to immediate evaluation that are based upon drug or alcohol levels rather than clinical presentation should be eliminated. At each level of care (acute, outpatient, residential, or inpatient) there should be programs available to accept patients without barriers or waiting lists. Patients should not be required to self-define as "psychiatric", "substance abuse" or "dual diagnosis" in order to be accepted for evaluation and treatment.

Integration: Psychiatric disorders and substance-related disorders are both examples of primary mental illnesses and the recommended treatment approach is integrated dual primary treatment that utilizes a disease and recovery model in a single setting or service system. Individuals should have a primary treatment relationship that coordinates ongoing treatment interventions for all disorders. Each disorder should receive specific and individualized treatment, which takes into account complications resulting from co-occurring disorders, clinical variables such as the phase of recovery, the extent of disability, and the presence of external supports (e.g. supportive family) or stressors (e.g. no family, criminal justice involvement).

Continuity: Since integrated treatment is significantly associated with better outcome and reduction of more expensive service utilization, a comprehensive service system must develop mechanisms for identifying patients with co-occurring disorders and establish a collaborative system of care management. The service system must be proactive to ensure continuity and prevent patients from "falling through the cracks". It should also seek out patients who are most disengaged and hardest to serve (e.g. individuals who are homeless). Services should be available regardless of initial motivation or adherence, and should include outreach and engagement. The system must be responsive to the needs of the patient, instead of patients needing to meet the specifications of the program or system.

Comprehensiveness: Due to the high prevalence, high cost, and poor outcomes of this population, AAAP recommends that all programs meet at least the standard of "dual diagnosis capability" (ASAM PPC 2R), with each program having defined responsibility for a cohort of individuals with co-occurring disorder, matched according to diagnosis, disability, phase of recovery, stage of change, and level of care.

AAAP members are primary providers of treatment for individuals with co-occurring disorders and were participants in a 1998 SAMHSA-funded national consensus panel project on co-occurring disorders. Recommendations of that panel were utilized in the development of this AAAP policy on the treatment of individuals with co-occurring psychiatric and substance use disorders.

Representative sample reference list of co-occurring disorders publications by AAAP members during the past 2 years:

Aviram RB. Rhum M. Levin FR. Psychotherapy of adults with comorbid attention-deficit/hyperactivity disorder and psychoactive substance use disorder. Journal of Psychotherapy Practice & Research. 10(3):179-86, 2001

Back SE, Dansky BS, Carroll KM, Foa EB, Brady KT. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures. J Subst Abuse Treat. 2001 Jul;21(1):35-45.

Ball, S.A., Rounsaville, B.J., Tennen, H., Kranzler, H.R. (2001) Reliability of personality disorder and trait dimensions in substance dependent inpatients. Journal of Abnormal Psychology, 110 (2): 341-352.

Ball, S.A., Jaffe, A.J., Crouse-Artus, M.S., Rounsaville, B.J., O’Malley, S.S. (2000) Multidimensional subtypes and treatment outcome in first time DWI offenders. Addictive Behaviors Vol. 25, No. 2, pp. 167-181.

Boutros NN, Gelernter J, Gooding DC, Cubells J, Young A, Krystal JH, Kosten TR. Sensory gating and psychosis vulnerability in cocaine-dependent individuals: Preliminary data. Biological Psychiatry 51:683-686, 2002.

Boyarsky BK. McCance-Katz EF. Improving the quality of substance dependency treatment with pharmacotherapy Substance Use & Misuse. 35(12-14):2095-125.

Brady KT, Dansky BS, Back SE, Foa EB, Carroll KM. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings. J Subst Abuse Treat. 2001 Jul;21(1):47-54.

Brook DW, Brook JS, Zhang C, Cohen P, Whiteman M. Drug use and the risk of major depressive disorder, alcohol dependence, and substance use disorders. Arch Gen Psychiatry. 2002 Nov;59(11):1039-44.

Cecero, J.J., Ball, S.A., Tennen, H., Kranzler, H.R., & Rounsaville, B.J.(1999) Concurrent and predictive validity of antisocial personality disorder subtyping among substance abusers. The Journal of Nervous and Mental Diseases. 187:478-486.

Ciraulo, DA & Nace, EP. Benzodiazepine treatment of anxiety or insomnia in substance abuse patients. Am. J. Addictions (2000) 9:276-84.

Compton WM, Cottler LB, Abdallah AB, Phelps DL, Spitznagel EL, Horton JC: Substance dependence and other psychiatric disorders among drug dependent subjects: Race and gender correlates. American Journal on Addictions, 2000; 9:113-125.

Compton WM, Cottler LB, Phelps DL, Abdallah AB, Spitznagel EL: Psychiatric disorders among drug dependent subjects: Are they primary or secondary? American Journal on Addictions, 2000; 9:126-134.

Compton WM, Cottler LB, Abdallah AB, Cunningham-Williams RM, Spitznagel EL. The effects of psychiatric comorbidity on response to an HIV prevention intervention. Drug and Alcohol Dependence, 2000; (58)3: 247-257.

Conway, K.P., Swedensen, J.D., Rounsaville, B.J., Merikangas, K.R. (2002) Personality, drug of choice, and comorbid psychopathology among substance abusers. Drug and Alcohol Dependence 65: 225-234.

Cornelius JR, Pringle J, Jernigan J, Kirisci L, Clark DB: Corrrelates of mental health service utilization and unmet need among a sample of male adolescents. Addictive Behaviors 26:11-19, 2001.

Cornelius JR, Lynch K, Martin CS, Cornelius MD, Clark DB: Clinical correlates of heavy tobacco use among adolescents. Addictive Behaviors 26:273-277, 2001.

Cornelius JR, Salloum IM, Lynch K, Clark DB, Mann JJ: Treating the 

substance-abusing suicidal patients. Annals of the New York Academy of Sciences 932:78-93, 2001.

Cornelius JR, Bukstein OG, Birmaher B, Salloum IM, Lynch K, Pollock NK, Gershon S, Clark D: Fluoxetine in adolescents with major depression and an alcohol use disorder: An open label trial. Addictive Behaviors 26:735-739, 2001.

Cornelius JR, Kirisci L, Tarter RE: Suicidality in offspring of men with substance use disorder: Is there a common liability? Journal of Child & Adolescent Substance Abuse 10:101-110, 2001.

Cornelius JR, Clark DB, Salloum IM, Bukstein OG, Kelly TM: Management of suicidal behavior in alcoholism. Clinical Neuroscience Research 1:381-386, 2001.

Cornelius JR, Salloum IM, Bukstein OG, Clark D: Psychiatric Comorbidity-Implications for Treatment and Clinical Research, Chapter 37, in The Handbook of Medical Psychiatry, Jair Soares, Samuel Gershon (eds.), 2002, 553-561.

Cornelius JR, Maisto SA, Pollock NK, Martin CS, Lynch KG, Clark DB: Rapid relapse generally follows treatment for substance abuse disorders among adolescents. Addictive Behaviors, (In Press).

Cornelius JR, Bukstein O, Salloum I, Clark D: Alcohol and Psychiatric Comorbidity, in Recent Developments in Alcoholism, volume XVI, Marc Galanter (ed.) (In Press).

Cottler LB, Nishith P, Compton WM: Gender differences in risk factors for trauma exposure and post-traumatic stress disorder among inner-city drug abusers in and out of treatment. Comprehensive Psychiatry, 2001;42:111-117.

Cunningham-Williams RM, Cottler LB, Compton WM, Spitznagel EL, Ben-Abdallah A. Problem gambling and comorbid psychiatric and substance use disorders among drug users recruited from drug treatment and community settings. Journal of Gambling Studies, 2000;16(4):347-376.

Davis, T.M., Carpenter, K.M., Malte, C.A., Carney, M., Chambers, S. & Saxon,A.J.: Women in addictions treatment: comparing VA and community samples. Journal of Substance Abuse Treatment 23:41-48, 2002.

Deas D, Randall CL, Roberts JS, Anton RF. A double-blind, placebo-controlled trial of sertraline in depressed adolescent alcoholics: a pilot study. Hum Psychopharmacol. 2000 Aug;15(6):461-469.

Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, Kola L, Lynde D, Osher FC, Clark RE, Rickards L. Implementing dual diagnosis services for clients with severe mental illness. Psychiatr Serv. 2001 Apr;52(4):469-76.

Egelko S, Galanter M, Dermatis H, Jurewicz E, Jamison A, Dingle S, De Leon G. Improved psychological status in a modified therapeutic community for homeless MICA men. J Addict Dis. 2002;21(2):75-92.

Fabiani, A. '" Simultaneous Pharmacological Treatment of Co-ocurring Disorders". World Congress of Psychiatry.Yokohama, Japan. August 24-29, 2002. Vol.2.FC-33-1.pp 38.

Galanter M. Self-help treatment for combined addiction and mental illness. Psychiatr Serv. 2000;51(8):977-9.

Gearon JS, Bellack AS, Rachbeisel J, Dixon L. Drug-use behavior and correlates in people with schizophrenia. Addict Behav. 2001;26(1):51-61.

George, T.P., Vessicchio, J.C., Termine, A., Bregartner, T.A., Feingold, A., Rounsaville, B.J., Kosten, T.R. (2002). A placebo-controlled trial of bupropion for smoking cessation in schizophrenia. Biological Psychiatry 52: 53-61.

George TP, Vessicchio JC, Termine A, Sahady DM, Head CA, Pepper WT, Kosten TR. Wexler BE. Effects of smoking abstinence on visuospatial working memory function in schizophrenia. Neuropsychopharmacology 26: 75-86, 2002

George, T.P., Ziedonis, D.M., Feingold, A., Pepper, W.T., Satterburgh, C.A., Winkel, J., Rounsaville, B.J., Kosten, T.R. (2000) Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia. American Journal of Psychiatry 157:1835-1842.

Hellerstein DJ, Rosenthal RN, Miner CR. Integrating services for schizophrenia and substance abuse. Psychiatric Quarterly. Vol 72(4) Win 2001, 291-306.

Hernandez-Avila, C.A., Burleson, J.A., Poling, J., Tennen, H., Rounsaville, B.J., & 

Kranzler, H.R. (2000) Personality, and substance use disorders as predictors of criminality in substance abusers. Comprehensive Psychiatry 41(4) : 276-283.

Hien DA, Nunes E, Levin FR, Fraser D. Posttraumatic stress disorder and short-term outcome in early methadone treatment. J Subst Abuse Treat. 2000;19(1):31-7

Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry 158(8): 1184-1190, 2001

Kosten TR, Fontana L, Sernyak M, Rosenheck R. Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse. J Nervous and Mental Disease 188: 454-459, 2000.

Levin FR, Evans SM, McDowell DM, Brooks DJ, Nunes E. Bupropion treatment for cocaine abuse and adult attention-deficit/hyperactivity disorder. J Addict Dis. 2002;21(2):1-16.

Levounis P, Galanter M, Dermatis H, Hamowy A, De Leon G. Correlates of HIV transmission risk factors and considerations for interventions in homeless, chemically addicted and mentally ill patients. J Addict Dis. 2002;21(3):61-72.

McCance, E.F., Carroll, K.M., Rounsaville, B.J. (1999) Gender differences in treatment seeking cocaine abusers: Implications for treatment. American Journal on Addictions, 8:300-311.

McCann BS, Simpson TL, Ries R, Roy-Byrne P. Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder. Am J Addict. 2000 Winter;9(1):1-9.

McGrath PJ. Nunes EV. Quitkin FM Current concepts in the treatment of depression in alcohol-dependent patients. Psychiatric Clinics of North America. 23(4):695-711, V, 2000.

McDowell DM, Levin FR, Seracini AM, Nunes EV. Venlafaxine treatment of cocaine abusers with depressive disorders. Am J Drug Alcohol Abuse 2000;26(1):25-31

Minkoff K, Zweben J, Rosenthal RN, Ries R. Development of service intensity criteria and program categories for individuals with co-occurring disorders. Journal of Addictive Diseases (in Press).

Minkoff K. Program components of a comprehensive integrated care system for seriously mentally ill patients with substance disorders. New Dir Ment Health Serv. 2001;(91):17-30.

Myrick H, Brady KT (2001). Management of comorbid anxiety and substance use disorders. Psychiatric Annals, 31(4), pp. 265-271.

Pettinati HM, Rukstalis MR, Luck GJ, Volpicelli JR, O'Brien CP. Gender and psychiatric comorbidity: impact on clinical presentation of alcohol dependence. Am J Addict. 2000 Summer;9(3):242-52.

Poling, J.C., Rounsaville, B.J., Ball, S., Kranzler, H., Tennan, H., Trifflemen, E.(1999). Rates of personality disorders in substance abusers: A comparison between DSM-III-R and DSM-IV. Journal of Personality Disorders, 13(4), 375-384.

Posternak MA, Mueller TI. Assessing the risks and benefits of benzodiazepines for anxiety disorders in patients with a history of substance abuse or dependence. Am J Addict. 2001 Winter;10(1):48-68. Review.

Ridenour TA, Cottler LB, Robins LN, Compton WM, Spitznagel EL, 

Cunningham-Williams RM. Test of the plausibility of adolescent substance use playing a causal role in developing adulthood antisocial behavior. Journal of Abnormal Psychology 2002;111:144-55.

Ries RK, Dyck DG, Short R, Srebnik D, Snowden M, Comtois KA. Use of case manager ratings and weekly urine toxicology tests among outpatients with dual diagnoses. Psychiatr Serv. 2002 Jun;53(6):764-6.

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Riggs PD, Davies RD. A clinical approach to integrating treatment for adolescent depression and substance abuse. J Am Acad Child Adolesc Psychiatry. 2002;41(10):1253-5.

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