02-5309. Request for Comments Regarding the Prevention, Identification, and Treatment of Co-occurring Disorders

In compliance with section 503A of the Public Health Service Act (42 U.S.C. 290aa-2a), the Substance Abuse and Mental Health Services Administration (SAMHSA) is required to provide to the United States Congress a report on the prevention, identification, and treatment of co-occurring disorders. Public comment is solicited in order to aid in the development of this report.

SUMMARY:

The report, due by October 17, 2002, is mandated to include the following:

• A summary of the manner in which individuals with co-occurring disorders are receiving treatment.
• A summary of improvements necessary to ensure that individuals with co-occurring mental illnesses and substance abuse disorders receive the services they need.
• A summary of practices for preventing substance abuse among individuals who have a mental illness and are at risk of having or acquiring a substance abuse disorder.
• A summary of evidence-based practices for treating individuals with co-occurring disorders and recommendations for implementing such practices.

We understand that your time is limited and you probably will not be able to respond to every issue. Where possible, however, it would be most helpful in responding to the key issues outlined below if you could identify those issues that you consider to be either a major problem or a minor problem. Further, for those issues that you consider to be a major problem, it would be helpful if you could explain the source of your concern and your recommendations for responding to the issue. Finally, you are in no way limited to the list below. If there are additional major problems related to the prevention, identification and treatment of co-occurring disorders that should come to the attention of SAMHSA, please describe and comment on those as well.

The issues are organized by topic area in an outline form. For example, issue A.1., “Commitment demonstrated by key decision-makers to address co-occurring disorders,” is under the System-Level topic area. It would be appreciated if you would provide your responses using the alphanumeric designations in this outline (e.g., A.1., B.1., etc.). This will allow us to process your indications of major and minor problem areas and your concerns and recommendations most efficiently.

A. System-Level Issues

1. Commitment demonstrated by key decision-makers to address co-occurring disorders.

2. Presence of an interagency coordinating body.

3. Presence of a strategic plan guiding community/interagency activities.

4. Opportunities for cross-training of staff.

5. Presence of interagency agreements.

6. Uniform application and eligibility criteria.

7. Pooled or joint funding.

8. Co-occurring disorders regarded as a likely presentation, not an exception.

9. Community efforts to reduce stigma of both disorders and encourage treatment.

B. Program-Level Issues

Access

1. Admission criteria that recognize the multifaceted needs of clients with co-occurring disorders.

2. Availability of professional staff trained in the area of co-occurring disorders.

3. Availability of staff whose culture(s) and language(s) match those of clients.

4. Services available at nontraditional hours (e.g. evenings and weekends).

5. Outreach to individuals not connected to the system.

Screening

6. Screening for both disorders.

7. Standardized instruments normed for gender and culture, and policies, and procedures that reflect gender and culture.

8. Level of accuracy in detecting the presence and severity of both disorders.

Assessment

9. Methods that allow for accurate recognition of the interaction between serious mental illnesses and substance abuse disorders.

10. Methods that are sufficiently comprehensive to allow for the entire range of client need.

11. Methods that are gender and culturally relevant.

Treatment

12. Process for flexible and individualized plans.

13. Use of clinical treatment guidelines for co-occurring disorders.

14. Use of staged interventions (e.g., engagement, persuasion, active treatment, relapse).

15. Longitudinal perspective.

16. Recognition of non-linear recovery process for both disorders.

17. Provisions for relapse.

18. Services for both disorders available concurrently, with the same agency.

19. Clients participate in developing treatment plans.

20. Availability of social support networks.

21. Assistance in securing needed wraparound services (housing, employment, childcare, etc.)

Follow-Up

22. Discharge planning policies and procedures that account for the full range of community supports that are required.

23. Long-term follow-up as standard practice.

24. Policies and procedures to address relapse to substance use and/or reoccurrence of psychiatric symptoms.

C. Prevention Issues

1. Interventions directed at risk and protective factors, rather than specific problem behaviors.

2. Longitudinal interventions (e.g., from kindergarten to high school).

3. Interventions designed for appropriate developmental stages.

4. Interventions that focus on the child at home and in school.

5. School-based programs that use a well-tested, standardized intervention with detailed lesson plans and student materials.

6.Family-based interventions that include skills training for parents.

7. Interventions that use media and community education strategies to increase public awareness and support.

8. Links between prevention programs and treatment systems.

9. Interventions that are universal (for all), selective (for those at risk), and indicated (for those at highest risk).

D. Research and Evaluation Issues

1. Availability of prevalence data for planning.

2. Availability of measures of access and cost.

3. Availability of measures of quality of care, including monitoring and quality assurance for the treatment of both disorders.

4. Availability of outcome measures, including quality of life, clinical and functional improvement, and maintenance and relapse prevention.

5. Data linked across programs and systems.

6. Management information systems designed to gather and analyze data on both disorders.

7. Adequate resources for data collection and evaluation.

DATES:

In order for comments to be considered in the development of this policy report on co-occurring disorders, they must be received no later than March 27, 2002.

ADDRESSES:

All comments should be sent to James Winarski; Advocates for Human Potential; 323 Boston Post Road; Sudbury, MA 01776.

FOR FURTHER INFORMATION CONTACT:

Eileen Elias, M.Ed., Special Expert, SAMHSA, 301-443-8742

Dated: February 28, 2002.

Richard Kopanda,

Executive Officer, SAMHSA.