Integrating Addiction and Mental Health Treatment within a National Addiction Treatment System: Using Multiple Statistical Methods to Analyze Client and Interviewer Assessment of Co-Occurring Mental Health Problems

Abstract

Aims

For a Swedish national sample of 12,833 individuals assessed for a substance use disorder (SUD) (2002-2008) in the Swedish welfare system, client self-report and clinical staff Addiction Severity Index (ASI) assessment data were used to assess mental health problem severity and needs.

Methods

Analysis of client self-report data using regression methods identified demographic characteristics associated with reporting significant mental health problems. Clinical staff assessment data from the ASI Interviewer Severity Rating (ISR) score were used to develop a K-means cluster analysis with three client cluster profiles: Narcotics (n=4795); Alcohol (n=4380); and Alcohol and Psychiatric Problems (n=3658). Chi-square and one-way ANOVA analyses identified self-reported mental health problems for these clusters.

Results

44% of clients had a history of using outpatient mental health treatment, 45% reported current mental health symptoms, and 19% reported significant mental health problems. Women were 1.6 times more likely to report significant mental health problems than men. Staff assessed that 74.8% of clients had current mental health problems and that 13.9% had significant mental health problems. Client and staff results were congruent in identifying that clients in the Alcohol profile were less likely (5%) to report having significant mental health problems compared to the other two profiles (30% each).

Conclusions

About 19% of clients with SUDs reported significant mental health problems, need integrated addiction and mental health treatment, and these clients are clustered in two population groups. An additional 25% of the addiction treatment population report current mental health symptoms and have at some point used mental health treatment. This national level assessment of the extent and severity of co-occurring disorders can inform decisions made regarding policy shifts towards an integrated system and the needs of clients with co-occurring disorders.

Keywords

substance abuse and mental health integration substance abuse and mental health treatment substance abuse and mental health systems Sweden addiction prevalence

References

Armelius

B-Å.

, & Armelius

(2011). En naturalistisk studie av 14000 svenska missbruksklienter baserad på Addiction Severity Index, ASI [A naturalistic study of 14000 Swedish substance abuse clients based on the Addiction Severity Index, ASI]. Missbruket, Kunskapen, Vården [Abuse, Knowledge, and Care] Missbruksutredningens forskningsbilaga [Abuse Survey Research Annex], 6, 97–167.

Armelius

B-Å.

, Nyström

, Engström

, & Brännström

(2009). Referensmaterial för bättre använding av ASI intervjun [Reference material for better use of the ASI interview]. The Institute for the Development of Methodology in Social Work. Social styrelsen (National Board of Health and Welfare). Stockholm, Sweden.

Brännström

, & Andréasson

(2008). Regional differences in alcohol consumption, alcohol addiction and drug use among Swedish adults. Scandinavian Journal of Public Health, 36, 493–503.

Brouselle

, Lamothe

, Sylvain

, Foro

, & Perreault

(2010). Integrating services for patients with mental and substance use disorders: What matters? Health Care Manage Rev, 35(3), 212–223.

Brousselle

, Lamothe

, Mercier

, & Perreault

(2007). Beyond the limitations of best practices: How program theory analysis helped reinterpret dual diagnosis guidelines. Evaluation and Program Planning, 30(1), 94–104.

Brunette

M. F.

, Mueser

K.T.

, & Drake

R. E.

(2004). A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders. Drug and Alcohol Review, 23, 471–481.

Burnam

M.A.

, & Watkins

(2006). Substance abuse with mental disorders: specialized public systems and integrated care. Health Affairs, 25(3), 648–658.

Cacciola

, Pecoraro

, & Alterman

(2008). Development of ASI psychiatric severity cut-off scores to identify co-occurring psychiatric disorders. International Journal of Mental Health and Addiction, 6, 77–92.

Clark

H.W.

, Power

, Le Fauve

C.E.

, & Lopez

E.I.

(2008). Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 3–13.

10.

Council on Legislation (2013). Reformed income tax rules for non-profit sector. Stockholm, Sweden: Council on Legislation.

11.

CSAT (Center for Substance Abuse Treatment) (2006). Treatment, volume 1: Understanding evidence based practices for co-occurring disorders. COCE overview paper 6. DHHS Publication No. (SMA) XX-XXXX. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services.

12.

CSAT (Center for Substance Abuse Treatment) (2007a). Understanding evidence based practices for co-occurring disorders. COCE overview paper 5. DHHS Publication No. (SMA) 07 4278. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services.

13.

CSAT (Center for Substance Abuse Treatment) (2007b). Systems integration. COCE overview paper 7. DHHS Publication No. (SMA) 07-4295. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services.

14.

CSAT (Center for Substance Abuse Treatment) (2007c). Services integration. COCE overview paper 6. DHHS Publication No. (SMA) 07-4294. Rockville, MD: Substance Abuse and Mental Health Services Administration.

15.

Dahlberg

, Waern

, & Runesson

(2008). Mental health literacy and attitudes in a Swedish community sample- investigating the role of personal experience of mental health care. BMC Public Health, 8:8.

16.

Donald

, Dower

, & Kavanagh

(2005). Integrated versus nonintegrated management and care for clients with co-occurring mental health and substance use disorders: a qualitative systematic review of randomised controlled trials. Social Science & Medicine, 60(6), 1371–1385.

17.

Drake

, Mercer-McFadden

, Mueser

, McHugo

, & Bond

(1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24(4), 589–608.

18.

Drake

, Mueser

, Brunette

, & McHugo

GJ.

(2004). A review oftreatments for people with severe mental illness and co-occurring substance use disorders. Psychiatric Rehabilitation Journal, 27(4), 360–374.

19.

Drake

R.E.

, Mueser

K.T.

, & Brunette

M.F.

(2007). Management of persons with co-occurring severe mental illness and substance use disorder: program implications. World Psychiatry, 6(3), 131–136.

20.

Engström

(2005). Implementation and evaluation of the Addiction Severity Index (ASI) in social services. Doctoral dissertation from the Department of Psychology, Umeå University, S-901 87 UMEÅ, Sweden: ISBN: 91-7305-927-7.

21.

Gerdner

(2004). Utfall av LVM-vård. I SOU 2004:3, Tvång och förändring. [Outcomes from compulsory care. In Compulsion and change, report from Swedish Government Official Enquiries].

22.

Grella

, & Stein

(2006). Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders. Psychiatric Services, 57(7), 1007–1015.

23.

Health Care Cost Institute. (2013). Issue Brief: The Impact of Mental Health Parity and Addiction Equity Act on Inpatient Admissions. Issue Brief #5 – January. From http://www.healthcostinstitute.org/issue-brief-impact-mental-health-parity-and-addiction-equity-act-inpatient-admissions

24.

Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: National Academies Press.

25.

Jeffery

, Ley

, McLaren

, & Siegfried

(2007). Psychosocial treatment programmes for people with both severe mental illness and substance misuse. Cochrane Schizophrenia Group, 2.

26.

Kokko

, Heinämäki

, Tynkkynen

L.-K.

, Haverinen

, Kaskisaari

, Muuri

, Pekurinen

, & Tammelin

(2009). Kunta ja palvelurakenneuudistuksen toteutuminen. Kuntakysely sosiaali- ja terveyspalvelujen järjestämisestä ja tuottamisesta [Implementation of the municipality and service stucture reform. Municipal survey on the organisation and production of social and health services]. Raportteja, 36. Helsinki: Terveyden ja hyvinvoinnin laitos.

27.

Kuussaari

, & Partanen

(2010): Administrative challenges in the Finnish alcohol and drug treatment system. Nordic Studies on Alcohol and Drugs, 27(6), 667–684.

28.

Landheim

, Bakken

, Vaglum

(2002). Sammansatte problemer og separate systemer. Psykiske lidelser bland rusmisbrukere til behandling i russektoren. [Complex problems and separated systems. Mental problems among addicts treated in addiction services.] Norsk epidemiology 12(3), 309–318.

29.

Lundgren

, Armelius

B.A.

, Chassler

, Brännström

, Armelius

, Sullivan

(2012). Beskrivning av tre klientprofiler inom svensk missbruksvård. Socialvetenskaplig tidskrift, (3-4), 200–216.

30.

McGahan

, Griffith

, Parente

, & McLellan

A.T.

(1986). Addiction severity index composite score manual. The University of Pennsylvania/Veterans Administration Center for Studies of Addiction. Supported by Grants from the National Institute of Drug Abuse (project DA 02254) and the Veterans Administration.

31.

McLellan

A.T.

, Kushner

, Metzger

, Peters

, Smith

, Grissom

, Pettinati

, & Argeriou

(1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9(3), 199–213.

32.

Minkoff

(2001). Best practices: developing standards of care for individuals with co-occurring psychiatric and substance use disorders. Psychiatric Services, 52(5), 597–599.

33.

Mueser

K.T.

, Noordsy

D.L.

, Drake

R.E.

, & Fox

(2003). Integrated treatment for dual disorders: A guide to effective practice. New York: The Guilford Press.

34.

Nesvaag

, & Lie

(2010): The Norwegian substance treatment reform: Between new public management and conditions for good practice. Nordic Studies on Alcohol and Drugs, 27(6), 655–666.

35.

Nyström

, Andrén

, Zingmark

, Bergman

(2010). The reliability of the Swedish version of the Addiction Severity Index (ASI). Journal of Substance Use, 15(5), 330–339.

36.

Öjehagen

(2011). Samsjuklighet mellan missbruk eller beroende och psykisk sjukdom. In Missbruket, kunskapen, vården. Missbruksutredningens forskningsbilaga (pp. 223–235).

37.

Pankow

, Simpson

D.D.

, George

, Rowan-Szal

Knight

, & Meason

(2012). Examining concurrent validity and predictive utility for the Addiction Severity Index and Texas Christina University (TCU) short forms. Journal of Offender Rehabilitation, 51(1-2).

38.

Rush

, Fogg

, Nadeau

, & Furlong

(2008). On the integration of mental health and substance use services and systems: Main report. Canadian Executive Council on Addictions; Ottawa.

39.

Sacks

, Chaple

, Sirikantraporn

, Sacks

J.Y.

, Knickman

, & Martinez

(2013). Improving the capability to provide integrated mental health and substance abuse services in a state system of outpatient care. Journal of Substance Abuse Treatment, 44(5), 488–93.

40.

Samet

, Waxman

, Hatzenbueheler

, & Hasin

(2007). Assessing Addiction Concepts and Instruments. Addiction Science Clinical Practice. December, 4(1), 19–31.

41.

SAMHSA. (2010). Results from the 2009 National Survey on Drug Use and Health: Mental health findings. Office of Applied Studies, NSDUH Series H-39, No. SMA 10-4609. Retrieved online from: http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/MH/2K9MHResults.pdf

42.

Statens offentliga utredningar (SOU) (2011). Bättre insatser vid missbruk och beroende (SOU 2011:35): Individen, kunskapen och ansvaret. Vol 2. Slutbetänkande av Missbruksutredningen. Fritzes. [Better response to abuse and addiction (SOU 2011:35): Individuals, knowledge and responsibility. Vol 2. Final report of the abuse investigation]. Stockholm: SOU, Ministry of Health.

43.

Sterling

, Chi

, & Hinman

(2011). Integrating care for people with co-occurring alcohol and other drug, medical, and mental health conditions. Alcohol Research & Health, 33(4), 338–349.

44.

Tomasson

, & Vaglum

(1995). A nationwide representative sample of treatment seeking alcoholics: a study of psychiatric comorbidity. Acta Psychiatrica Scandinavica, 92(5), 378–385.

45.

U.S. House Report 109–143 (2006). Committee on Appropriations, Departments 680 of Labor, Health and Human Services, and Education, and Related Agencies Appropriation Bill, 2006. Retrieved from www.thomas.loc.gov

46.

Wahlbeck

(2010). Moving towards integrated addiction treatment systems. Nordic Studies on Alcohol & Drugs, 27(6), 699–702.

47.

Weisner

, Hinman

, Lu

, Chi

, & Mertens

(2010). Addiction treatment ultimatums and U.S. health reform: a case study. Nordisk Alkohol och Narkotikatidskrift, 27(6), 685–698.

48.

WHO Regional Office for Europe (2010). User empowerment in mental health – a statement.

49.

WHO Regional Office for Europe. Copenhagen. Retrieved online from: http://www.euro.who.

50.

Wicks

S. J.

(2004). Perspectives on staff resistance to using the ASI. Journal of Substance Use, June, 9(3–4), 172–175.