Co-occurring Mental Illness and Drug Addiction Treatment: Overview and Bibliography

Allison C. Colker, Esq. and Eileen Crean, Esq.

With special recognition to the National Association of State Mental Health Program Directors (NASMHPD) and
the National Association of State Alcohol/Drug Abuse Directors (NASADAD) for their comments.

December 31, 2004

Introduction

Treatment of co-occurring mental and addictive disorders is an issue requiring state and local agency action, in collaboration with state legislators, who can play a role in monitoring, financing and evaluating co-occurring treatment services and encouraging the broad collaboration between state mental health and substance abuse authorities that is necessary to improve systems of care. This issue brief is intended to provide the reader with a general overview of the issues involved in designing and maintaining an adequate system of care for individuals with co-occurring disorders, based on the recent work of the NASMHPD-NASADAD Task Force on Co-occurring Mental Health and Substance Use Disorders.¹

One promising approach now emerging within the public mental and addictive disorders treatment systems is the use of a conceptual framework that places individuals with co-occurring disorders within one of four quadrants, based on the severity of their mental illness and alcohol and drug addiction. Using the framework as a foundation for discussion, providers of treatment for mental and addictive disorders, funders, policymakers, consumers, family members and others can consider whether their service systems offer the necessary mix of consultation, collaboration and fully integrated treatment required by individuals who are receiving care within primary health care settings, substance abuse treatment agencies, mental health treatment agencies, corrections facilities and hospital facilities (including emergency rooms).

Overview

The root of the problem in coordinating treatment for people with co-occurring mental and addictive disorders can be traced to at least the late 18th and early 19th centuries, when American medical leaders called for the creation of separate asylums for the "insane" and "inebriates." Inebriates might be excluded from psychiatric institutions because their substance abuse was thought to be willful behavior and not treatable, although, in practice, psychiatric hospitals often were the sole housing or treatment option available.

A series of federal legislative actions represent important contemporary benchmarks in the development of treatment systems of care for mental and addictive disorders.

P.L. 88-164. The Community Mental Health Centers Act of 1963. ²
P.L. 89-793 The Narcotic Addict Rehabilitation Act (NARA) of 1966.³
P.L. 91-616. Created the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in 1970. ⁴
P.L. 92-255. Created the National Institute of Drug Abuse (NIDA) in 1971.⁵
P.L. 93-282. Placed NIMH, NIAAA, and NIDA as equal partners under the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA).⁶
P.L. 97-35. The Omnibus Budget Reconciliation Act of 1981. Combined State Formula Grants and many categorical grants into an Alcohol, Drugs and Mental Health (ADM) Block Grant to each state.⁷
P.L. 102-321. The Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) was reorganized in 1992 into a new health service agency, the Substance Abuse and Mental Health Services Administration (SAMHSA).⁸

States have responded in their own unique ways to accommodate this federal legislative history. All states continue to incorporate both substance abuse and mental health authorities within state government, although the particular location, structure and functions of these authorities vary widely. All states have some capacity to treat people with co-occurring mental and addictive disorders, although the nature, extent and effectiveness of that capacity vary widely. The development and maintenance of effective services for people with co-occurring disorders are directly related to available financing, legislative and regulatory constraints, and readiness of both fields to bring about the necessary changes to treatment systems.⁹ Virtually all states experience a significant gap between the number of individuals in need of publicly supported treatment of mental and addictive disorders, and the number that can effectively be served within existing resources. Some experts contend that redistribution of existing resources to programs designed exclusively for co-occurring clients may broaden that treatment gap.

The SAMHSA-funded Integrated Data Base Project recently conducted a comprehensive review of data from a sample of three states (Delaware, Oklahoma and Washington), that were selected for their ability to provide integrated data on substance abuse, mental health treatment and Medicaid expenditures.¹⁰ Two of the study's most significant findings included: (1) people with co-occurring disorders were more likely to be treated under state mental health and substance abuse agencies than under Medicaid; and (2) among those individuals treated by state agencies, about half were treated under both the mental health and substance abuse agency, while the other half were treated almost exclusively by the mental health agencies. Many local alcohol and other drug treatment providers (AOD) report a capability to treat clients who suffer from both mental and addictive disorders. According to SAMHSA’s Drug and Alcohol Services Information System (DASIS) Report (May 24, 2002), nearly half the nation's specialized substance abuse treatment facilities provided programs for dually-diagnosed clients.¹¹

Although some attempts have been made to integrate the treatment of mental and addictive disorders within community mental health centers, the fields of mental and addictive disorders treatment have ultimately developed separately, fueled by their separate histories, ideologies and funding streams. Now, at the dawn of the 21st century, an increased ability to identify people with co-occurring disorders and a greater consciousness of the full range of their needs are challenging the limited available resources as never before. Many of these individuals are homeless, have multiple significant health problems (e.g., HIV/AIDS) and have been incarcerated at some point in their lives. In general, long-term health outcomes are poor for people with co-occurring mental and addictive disorders. Because co-occurring disorders exact an immense economic and human toll on society, they should be given high priority when states are designing effective health care delivery systems.

Until quite recently, the evolution of clinical response to the challenges presented by this population has tended to be idiosyncratic to individual local treatment providers or, in some limited cases, consistent with guidelines established through individual state co-occurring project initiatives (e.g., Connecticut, Missouri, New Jersey, Pennsylvania and Texas). The NASMHPD-NASADAD Task Force and the conceptual framework represent not only a significant departure from previous independent or isolated program development efforts, but also represent the first nationally organized attempt to develop informed strategic plans that then may be applied to improve co-occurring services at the national, state and local levels.

As of October 2002, the NASMHPD-NASADAD Task Force has met on three separate occasions, approximately once per year since its establishment. At its first meeting in June 1998, the task force focused on development of the conceptual framework. The resulting publication, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders, elaborated on the nature of the problem, then presented and explained the conceptual framework.¹² At its second meeting in June 1999, the task force identified mechanisms to both finance and market the conceptual framework to interested constituents (including legislators and other policymakers) and established the expectation that comprehensive and coordinated systems of care for individuals with co-occurring disorders should be developed. The resulting publication, Financing and Marketing the New Conceptual Framework for Co-Occurring Mental Health and Substance Abuse Disorders: A Blueprint for Systems Change, was produced in April 2000. Later that same year, the task force oversaw development of a publication that represented one of the earliest efforts to identify state examples of effective co-occurring service programs: Successful Programs for Individuals with Co-Occurring Mental Health and Substance Abuse Disorders: Examples from Five States (August 2000). Programs in 5 states--Massachusetts, New York, Pennsylvania, Washington and Wisconsin--are profiled in this publication.

The most recent meeting of the task force occurred in November 2001. Task force members considered the results of case studies that were conducted at nine sites during the previous year under its sponsorship. Programs in 9 states--Maine, Colorado, Virginia, Ohio, Tennessee, Pennsylvania, Illinois, Texas and Maryland--were the subject of in-depth case studies. These sites in each state were selected on the basis of their demonstrated success in financing and delivering fully coordinated co-occurring mental and addictive disorders services.

In addition to the state mental health agency directors, state substance abuse agency directors, national provider organizations and federal agency representatives that were involved in previous task force meetings, the 2001 site-specific participants included the executive directors of two of the nine case study sites. Their experience and perspective contributed significantly to the discussion as the task force sought to review project findings and assist in identifying and synthesizing the key program and fiscal elements that crosscut the case studies. The publication that resulted from that meeting, Exemplary Methods of Financing Integrated Service Programs for Persons with Co-Occurring Mental Health and Substance Use Disorders, will be published in November 2002. The final report has been selected as an appendix to the recently completed "Report to Congress" regarding delivery of services to people with co-occurring mental and addictive disorders, that was authored, as required by Congressional Order, by the Substance Abuse and Mental Health Services Administration.

Creating an Effective System of Care

According to the task force:

The needs of persons with co-occurring mental and addictive disorders are varied and complex. Historically, the nation’s treatment systems for mental and addictive disorders have responded to these needs in a fragmented and uncoordinated fashion. Our responses have reflected significant differences in the way co-occurring disorders are understood and defined, as well as in the way that co-occurring treatment services are developed, financed and delivered. While differences of opinion and approach remain, mental and addictive disorders professionals increasingly recognize an urgent need to create more responsive systems of care. Without more effective care, individuals with co-occurring mental and addictive disorders will continue to cycle repeatedly through service systems, enter jails and judicial systems and generally go without the services and supports they need to relieve and resolve their disorders.¹³

In these four reports, the task force outlines a series of challenges to creating an effective system of care, explains the conceptual framework, identifies some of the characteristics of successful treatment programs, and recommends actions that can be taken at federal, state and local levels to improve services for people with co-occurring mental and addictive disorders. This issue brief reviews these areas.

Challenges to an Effective System of Care

Providers of treatment for mental and addictive disorders frequently lack an adequate working knowledge of each other's disciplines and systems, in part because of an absence of training mechanisms, including cross-training in medical schools. Concern that integration--or even close collaboration--could lead to one system subsuming the other has led to a lack of trust, which also has significantly hampered the development of a working relationship between the two fields. Different clinical practice approaches and treatment philosophies--such as excluding people on psychiatric medications from drug--free substance abuse treatment programs or requiring that an individual maintain abstinence in order to access treatment in a mental health setting--also constitute barriers to adequate treatment. The absence of a common language, both between and within the substance abuse and mental health communities, leads to confusion and is symptomatic of the lack of consensus about these illnesses. Terms such as "dual diagnosis," "mental illness and chemical abuse (MICA)," "dual disorders" and "co-morbidity," for example, are used to describe differing perspectives on how to characterize the group of individuals referred to in this brief as having "co-occurring disorders."

Creating coordinated funding streams at the state, federal and local program levels for a comprehensive system of care is also a challenge. Numerous barriers to funding the treatment of co-occurring disorders exist. One such barrier is the absence of shared systems for co-occurring disorders that would be driven by shared funding. There is also institutional resistance to merging funding streams. Furthermore, statutes and regulations frequently create barriers to the development of creative and effective treatment models by limiting program flexibility (e.g., in most states, a co-occurring treatment program must choose to be licensed either as a substance abuse treatment provider or a mental health treatment provider, but not as both). Coordination of funding streams at the local or county level is essential to providing the most effective treatment, but often is lacking. In light of current budgetary restraints, obtaining significant levels of new funding dedicated to the treatment of co-occurring disorders is unlikely. States and communities may need to consider a mixed model that combines different streams of existing funds and also leverages some new resources.

Characteristics of a Successful System of Care

The following key elements were identified during discussions of the NASMHPD-NASADAD task force as essential to creating and maintaining a successful system of care.

Systems change will be easier to achieve if mental health and substance abuse systems share a joint vision and joint values that clarify the importance of their efforts. Key stakeholders must agree about the need for, and the value of, treatment systems working together in consultation, collaboration and even integration, to improve consumer outcomes.

The system must be consumer-centered and culturally competent, where consumers and their families play active and key roles in system design and individual treatment decisions.

Referred to as a "no-wrong door" approach, services for people with co-occurring disorders must be available and accessible wherever and whenever the person enters a service system.

Treatment must be comprehensive, longitudinal, and increased or decreased according to changing individual consumer needs and motivation.

There must be a focus on engaging those who are not currently in treatment in the mental health or substance abuse treatment systems.

Although the systems themselves do not need to be integrated, service delivery must be closely coordinated for clients with co-occurring disorders, creating a seamless system of care for the consumer. Depending on the severity of the co-occurring illness, the level of coordination between substance abuse and mental health professional staff may range from consultation (i.e., a telephone request for information from one agency to another), to collaboration (i.e., interagency staffing conferences where both mental health and substance abuse professionals contribute to the treatment plan), to integration (i.e., the full range of services for both mental illness and substance abuse is provided by the same group of professionals at the same time).

Frontline staff from the various systems must trust and respect one another.

There must be cross-training between disciplines. In addition, primary health care providers also would benefit from further training in the treatment of mental and addictive disorders.

There must be common data, assessment tools, and performance indicators to help providers in both systems determine the nature and severity of an individual's mental and addictive disorders and plan effective treatment and follow-up care. Shared performance indicators also can improve systems analysis to determine whether stated outcomes are being met. Because funding is likely to be limited, getting the most from each dollar by ensuring the purchase of services based on good science is imperative. Findings from pilot studies, research and demonstration projects should be utilized. State and community agencies also must develop targeted requests for proposals (RFPs) that set clear expectations for program performance based on available research and on the community's needs. The best way to determine a program's performance is to measure improved consumer outcomes. Performance-based contracting should be used to tie financial incentives and disincentives to the achievement of measurable outcomes.

Flexible funding is a necessary tool if local mental health and substance abuse providers are to meet the needs of individuals whose disorders do not fall neatly into one or another categorical funding stream. A key to obtaining funding for an effective system of care for co-occurring disorders is a commitment on the part of leaders to bring stakeholders together to move the planning process forward. In most successful state-level demonstration programs for people with co-occurring disorders, for example, the state mental health agency and the state alcohol and drug abuse agency jointly planned and purchased services. Members of the NASMHPD-NASADAD task force are united in their belief that sharing resources at the local service delivery level is the best way to ensure that an individual consumer obtains the specific services he or she needs.

A Conceptual Framework for Treatment: The Quadrant System

Modified from a model originally used in New York, a conceptual framework for treatment that is flexible, cost-effective, client-centered and evidence-driven was developed by the task force. Use of the framework helps key stakeholders speak the same language about symptom severity, locus of care, and the level of service coordination needed to address co-occurring disorders. The vast majority of the research literature, and the bulk of the money invested, tends to focus on people with serious mental illnesses who also have substance abuse problems. This framework, which takes a much broader approach, is designed to ensure enough flexibility to address the needs of all individuals with co-occurring disorders; to fit into any service setting; and to allow policymakers, providers and funders to plan and fund services for individuals regardless of the current structure of a state or community's health care delivery system.

Under the framework, co-occurring disorders are conceptualized in terms of the number and severity of symptoms, rather than specific diagnoses. In addition, the levels of service coordination--including consultation, collaboration and integration--needed to improve consumer outcomes are specified and defined. The level of service coordination recommended under the framework is directly related to the level of severity of the disorder; the higher the level of severity, the higher the level of coordination needed.

Finally, the framework points to the need for special attention to three groups of individuals: 1) individuals, especially children and adolescents, who are at risk of developing serious disease; 2) individuals engaged in one of the two treatment systems where the other, less severe, aspect of the co-occurring disorder remains a lower priority for treatment; and 3) individuals with more severe mental and addictive disorders, who are found in inappropriate settings--including jails, emergency rooms, or living on the streets--who use the most resources and have the worst outcomes.

Levels of Illness Severity

The underlying assumption of the model is that the severity of an individual's mental illness and/or substance abuse disorder may vary from high severity to low severity at any given time. The model uses four major categories of illness severity:

Category I. Less severe mental disorder/less severe addictive disorder;
Category II. More severe mental disorder/less severe addictive disorder;
Category III. Less severe mental disorder/more severe addictive disorder; and
Category IV. More severe mental disorder/more severe addictive disorder.

Because of the opportunity for prevention, Category I, which includes many children and adolescents, is arguably one of the most important categories of individuals upon which states should focus their treatment resources and funding. It is believed that early intervention can prevent the development of more serious disorders which if left inadequately treated, will result in much greater financial and human costs to society. At the other end of the scale, Category IV represents the group of individuals who currently use a disproportionate share of service funding because their illnesses are the most severe and because they are found in the most expensive treatment and institutional settings, including inpatient hospital settings, emergency rooms and jails. This group also represents a priority population upon which states should arguably focus treatment resources and funding because they exact the greatest human and financial tolls on society.

Level of Service Coordination by Severity

Based on the severity of their disorders and the location of their care, levels of coordination among the substance abuse, mental health and primary health care systems are recommended under the framework to address the needs of individuals with co-occurring mental and addictive disorders. Informal consultation is the lowest level of coordination, which might include such things as telephone requests for information or advice. Coordination at this level ensures that both mental and addictive disorders are sufficiently understood by all parties to allow for effective identification, engagement, prevention and early intervention.

More formal collaborations that ensure that treatment regimens encompass interventions for both mental and addictive disorders--such as interagency staffing conferences where representatives of both substance abuse and mental health agencies contribute to the design of a treatment program--represent the next level of coordination. At this level, a much greater focus is placed upon the creation of an individualized treatment plan that then is implemented under the auspices of one system or the other. At the highest end of the scale is services integration, where the treatment of mental and addictive disorders are merged into one treatment plan and one treatment setting.

Recommendations of the Joint Task Force for Federal, National and State Action

To eliminate the need for state and local providers to develop a plan or system that already exists, SAMHSA should identify and broadly disseminate information about successful approaches to consultation, collaboration and integration for people with co-occurring disorders. National associations such as NASMHPD and NASADAD can participate in this process by working together to build consensus on the issue of co-occurring disorders; by acting as a conduit for joint initiatives that include all key stakeholders, including state legislators, cabinet secretaries, providers, consumers, and their families; and by ensuring that the issue of co-occurring disorders remains a high priority.

At the state level, state policymakers--including state mental health commissioners and alcohol and substance abuse directors--should consider the adopting the conceptual framework developed by the joint NASMHPD-NASADAD task force to create effective systems of care for those with co-occurring mental and addictive disorders. State mental health and alcohol and substance abuse agencies might enter into formal agreements that delineate the scope of consultation, collaboration and integration the state will expect and support, as well as funding strategies and training initiatives, including cross training. State commissioners and directors also can use the conceptual framework as an educational tool in discussions with their governors and legislators. In the interest addressing treatment of co-occurring disorders and the financing thereof, state legislators can ensure that their mental health and substance abuse agency directors are working together and collaborating.

County and community leaders can offer substantial educational support to state legislators in support of this process. Some of the most innovative efforts to address the needs of people with co-occurring mental and addictive disorders have been developed in communities around the country. States can encourage such efforts by funding pilot projects that focus on such critical issues as the best way to integrate services for people with co-occurring disorders and the types of outcomes that can and should be measured. Details about successful projects can be included in information about best practices collected and disseminated by the federal agencies and national associations.

Notes

The task force is comprised of members of the National Association of State Alcohol and Drug Abuse Directors and the National Association of State Mental Health Directors. Support for the work of the task force has been provided by the Center for Mental Health Services and the Center for Substance Abuse Treatment within the Substance Abuse and Mental Health Services Administration.
Expanded the services programs funded by the National Institute of Mental Health (NIMH), originally created in 1946 by P.L. 79-487, and established grants for Community Mental Health Centers. The intent of the Act was, in part, to provide a full range of community-based care for individuals being discharged from state psychiatric hospitals back into their communities. The legislation marked a new era of federal involvement in mental health services, previously seen as primarily a state and local governmental responsibility.
Replaced the Federal system of civil and criminal commitment in isolated prison hospitals with a system of civil commitment and voluntary treatment in community based agencies. The act laid the groundwork for a Federally funded national system of treatment for drug addicts, although the decision to proceed with such a system was not made until 1971 with the creation by Executive Order of the Special Action office for Drug Abuse Prevention.
Created within NIMH in 1970, by the Hughes Act, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was given responsibility for the research, training and services grants directed at this disease. Provided for a State Alcohol Formula Grant to each state. States were required to designate a State Alcohol Authority (SAA) to plan for and administer the State Alcohol Formula Grants.
The National Institute of Drug Abuse (NIDA) was created within NIMH in 1973, assuming the operational responsibilities of the Special Action Office on Drug Abuse Prevention, given responsibility for the research, training and services grants directed at this disease, and for a State Drug Formula Grant to each state. States were required to designate a Single State Authority (SSA) for Drug Abuse to plan for and administer the State Drug Formula Grants.
The Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment Act Amendments of 1974.
The amount of services funding was reduced by twenty five per cent as the change in grant format reduced Federal reporting requirements. The requirements for States to designate a State alcohol or drug abuse authority to plan for and administer the formula grants were also repealed and the Governor was designated as responsible for meeting the block grant requirements.
The Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) was reorganized in 1992 into a new health service agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Public Health Service of the U.S. Department of Health and Human Services (DHHS). SAMHSA’s mission is to reduce the incidence and prevalence of alcohol and other drug use and mental disorders, improve treatment outcomes for people who suffer from these disorders, and diminish consequences for their families and communities. SAMHSA consists of three centers: the Center for Substance Abuse Treatment (CSAT), the Center for Substance Abuse Prevention (CSAP) and the Center for Mental Health Services (CMHS). Coordination is provided by the Office of the Administrator. The three research institutes that were part of ADAMHA when it was created in 1974--NIMH, NIAA and NIDA--were transferred to the National Institutes of Health. The Alcohol, Drugs and Mental Health (ADM) Block Grant was split into the Community Mental Health Services Block Grant and the Substance Abuse Prevention and Treatment Block Grant.
For example, the Community Mental Health (CMH) Block Grant explicitly permits payment for co-occurring services to be delivered only to those consumers who meet criteria for severe and persistent mental illness or severely emotionally disturbed children. The Substance Abuse Prevention and Treatment (SAPT) Block Grant allows treatment for co-occurring disorders, but only if funds are expended for purposes for which they were authorized by law and can be tracked for accounting purposes.
SAMHSA, Mental Health and Substance Abuse Treatment: Results from a Study Integrating Data from State Mental Health, Substance Abuse and Medicaid Agencies, (Rockville, Md.: SAMHSA, 2001).
SAMHSA, The DASIS Report, (Rockville, Md.: SAMHSA, May 2002).
This and all other publications produced by the task force are included in the bibliography of this issue brief.
NASMHPD and NASADAD, Exemplary Methods of Financing Integrated Service Programs for Persons with Co-Occurring Mental Health and Substance Use Disorders (Alexandria, Va. and Washington, D.C.: NASMHPD and NASADAD, November 2002).

Bibliography

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Selected references that can provide further background and assistance for States wishing to further address these issues.

Annotated Bibliography

Center for Mental Health Services. Annotated Bibliography: Co-Occurring Mental and Substance Disorders (Dual Diagnosis) Panel. Rockville, Md.: CMHS, 1997.
Center for Mental Health Services Technical Assistance documents
Center for Mental Health Services. Co-Occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula. Report of the Center for Mental Health Services Managed Care Initiative: Clinical Standards and Workforce Competencies Project. Rockville, Md.: CMHS, 1998.
___________. Addressing the Needs of Homeless Persons with Co-Occurring Mental Illnesses and Substance Use Disorders. Rockville, Md.: SAMHSA, 1997.
__________. Implementing Interventions for Homeless Individuals with Co-Occurring Mental Health and Substance Use Disorders. Rockville, Md.: SAMHSA, 1996.

Epidemiological/descriptive studies of co-occurring disorders

Drake, R.E.; A.I. Alterman; and S.R. Rosenberg. "Detection of Substance Use Disorders in Severely Mentally Ill Patients." Community Mental Health Journal 29 (1993): 175-192.
Kessler, R.C., et al. "The Epidemiology of Co-Occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization." American Journal of Orthopsychiatry 66, no 1 (1996): 17-31.
National GAINS Center. The Prevalence of Co-Occurring Mental and Substance Abuse Disorders in the Criminal Justice System. Delmar, N.Y.: National GAINS Center, 1997.
Schuckit, M.A., and V. Hesselbrock. "Alcohol Dependence and Anxiety Disorders: What is the relationship?" American Journal of Psychiatry 151 (1994): 1723-1734.

Service Delivery Design Issues

Minkoff, K. "Integration of Addiction and Psychiatric Services." Managed Mental Health Care in the Public Sector. Amsterdam: Harwood Academic Publishers, 1997, 233-245.
_________. "Program Components of a Comprehensive Integrated Care System for Serious Mentally Ill Patients with Substance Disorders." New Directions for Mental Health Services 30 (1991): 13-27.
National Association of State Alcohol and Drug Abuse Directors, Preliminary Information on Services to Individuals with Co-Existing Substance Abuse and Mental Health Disorders. NASADAD report submitted to CSAT. Washington, D.C.: NASADAD, 1997.
National Association of State Alcohol and Drug Abuse Directors and National Association of State Mental Health Program Directors, Substance Abuse and Mental Health Services Linkages with Primary Care: Analysis of State Surveys and Case Studies. Joint NASADAD and NASMHPD draft report to HRSA. Washington, D.C. and Alexandria, V.A.: NASADAD and NASMHPD, 1998.
National Health Policy Forum. "Dual Diagnosis: The Challenge of Serving People with Concurrent Mental Illness and Substance Abuse Problems." Issue Brief. Washington, D.C.: NHPF, 1997, 718.
Osher, F. "A Vision for the Future: Toward A Service System Responsive to those With Co-Occurring Addictive and Mental Disorders." American Journal of Orthopsychiatry 66, no. 1 (1996): 71-76.
Substance Abuse and Mental Health Services Administration National Advisory Council. Improving Services for Individuals at Risk of, or with, Co-Occurring Substance-Related and Mental Health Disorders. Rockville, MD: SAMHSA, 1997.
Ridgely, M. Susan; H. Goldman; and M. Willenbring. "Barriers to the Care of Persons with Dual Diagnosis: Organization and Financing Issues," Readings in Dual Diagnosis. Columbia, Md.: IAPSRS, 1998, 399-414.
Sciacca, K., and C.M. Thompson. "Program Development and Integrated Treatment Across Systems for Dual Diagnosis: Mental Illness, Drug Addiction, and Alcoholism (MIDAA)." Journal of Mental Health Administration 23 (1996): 3.

Treatment-related and Treatment Efficacy studies

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