State Commissioners Say No To Integrated Treatment
Members of the Senate Committee on Health, Education, Labor, and Pensions (HELP) are in the midst of deliberations to finalize legislation to reauthorize the Substance Abuse and Mental Health Services Administration (SAMHSA). NAMI and members of the mental health community have been advocating for SAMHSA reauthorization to include effective and equitable integrated-treatment programs for persons with co-occurring disorders co-financed through SAMHSA’s two block grants, the mental health block grant and the substance abuse block grant.
National studies commissioned by the federal government estimate that 10 million Americans have co-occurring mental and addictive disorders. The addictive-disorder community has argued against a shared responsibility for persons with co-occurring illnesses. On June 23, the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD) issued a joint announcement rejecting any blended funding for integrated treatment for people with co-occurring disorders.
The prevailing scientific evidence shows that treating co-occurring disorders one at a time (sequential) or in different treatment plans (parallel) has been a failure for people with dual diagnoses. Furthermore, these studies and others have found that integrated treatment programs are superior to non-integrated treatment. (A list of research studies can be found at the end of this email.) NAMI and the mental illness community are simply requesting that both the state mental health and state substance abuse systems each have some responsibility for serving persons with co-occurring disorders through integrated treatment.
All NAMI members are encouraged to continue their advocacy on this important issue by contacting your members of Congress and Governor, and urge them to enable governors to blend some mental health and substance abuse block grants funds for integrated treatment for persons with co-occurring disorders. All members of Congress can be reached by going to the policy page of the NAMI website at www.nami.org/policy.htm and clicking on "Write to Congress," or by calling the Capitol Switchboard at 202-224-3121.
Further, ask your state mental health director why NASMHPD rejected blending some federal block grant funds for integrated treatment programs.
1. NAMI and other mental health advocates originally advocated:
A State receiving amounts under Section 1911 or 1921 may use a portion of such amounts to fund integrated treatment services for children, youth, and adults who have co-occurring serious mental illness and addictive disorders. The Secretary shall obtain appropriate program data on integrated treatment programs. In administering this section, the Secretary shall ensure that federal reporting requirements do not unduly hinder or pose a barrier to States’ ability to combine or commingle funds from Section 1911 or 1921 in order to provide an integrated program of services to individuals with co-occurring disorders.
2. SAMHSA subsequently accepted:
States may use funds available for treatment under section 1911 and 1921 to treat persons with co-occurring substance abuse and mental disorders as long as funds available under section 1911 and 1921 are used for the purposes for which they were authorized by law and can be tracked for accounting purposes. The Secretary is encouraged to ensure that the reporting and auditing requirements of the programs under section 1911 and 1921 do not present an undue barrier to providing services, including integrated treatment, for people with co-occurring mental health and substance abuse disorders." SAMHSA staff subsequently added "shall provide technical assistance to States" after Secretary in the second sentence, in response to a request from the mental health groups. This was a major accomplishment to move SAMHSA, after all these months.
This language comes from a revised June 11 SAMHSA policy position statement on co-occurring disorders. NAMI commends SAMHSA for officially modifying their previous statements and for now endorsing state discretion to develop integrated treatment programs.
3. The June 23 "NASADAD-NASMHPD Agreement on Wording For SAMHSA Reauthorization" reads:
"States may use funds available for treatment under sections 1911 and 1921 to treat persons with co-occurring substance abuse and mental disorders as long as funds available under sections 1911 and 1921 are used for the purposes for which they were authorized by law and can be tracked for accounting purposes." This is the NASADAD position since January. NASMHPD completely caved in to be friends with their fellow state officials. If enacted into law, it would negate what SAMHSA announced on June 11. It betrays months of collaboration with the national mental health organizations working on this issue. Betrayal is the feeling the advocates are having. The language does not mention either integrated treatment nor undue barriers. The effect of this language is to continue a failed system of silo-based parallel and sequential treatment for this population. Public bureaucracies need not modify their services. They can continue to finance parallel and sequential treatment; treatment which by design largely fails.
RESEARCH STUDIES AFFIRMING INTEGRATED TREATMENT
" The failure of the parallel treatment system for dually diagnosed persons is …reviewed followed by a description of more recently developed integrated substance abuse and mental health methods."
National Institute of Drug Abuse Research Monograph Series 172, "Treatment of Drug Dependent Individuals With Comorbid Mental Disorders," 1997
" By the late 1980s it had become increasingly clear that the traditional approach of treating dually diagnosed clients through separate mental health and substance abuse service systems was inadequate…A wide range of problems occurred with the parallel and sequential approach to treating comorbid psychiatric and substance use disorders..."
Mueser, Drake, and Miles, cited in April 2, 1999 correspondence between former SAMHSA Advisory Committee member Max Schneier, J.D., and NIH Director Harold Varmus
" These studies, therefore, are consistent with the hypotheses that patients with dual disorders can be successfully rehabilitated from substance abuse disorders and that integrated treatments are superior to nonintegrated treatments." (pg. 601)
Drake, Mercer-McFadden, Mueser, McHugo,and Bond; "Review of Integrated Mental Health and Substance Abuse Treatment for Patients With Duel Disorders." In: Schizophrenia Bulletin. Vol. 24, No. 4, 1998, pages 589-607
" Both professional and organizational rivalries and jealousies often conspire to add to the difficulties faced by individuals with dual disorders." "Most professionals in each field have been trained to work only with individuals having a single disorder; reformers underscore the need for cross-training of professionals in each field to improve services to patients with dual diagnosis."
National Health Policy Forum. "Dual Diagnosis: The Challenge of Serving People with Concurrent Mental Illness and Substance Abuse Problems." Washington, DC: April 14, 1998
" NIDA Director Alan Leshner called integration of care a truism- ‘How can you ever be against it?’ What is needed, he said, is research on how to deliver it. He pointed to extensive research showing parallel or sequential treatment does not work. ‘I would argue we have failed miserably under a fragmented system’, he said."
"Experts Address Barriers to Treatment of People with Co- Occurring Disorders", In: Mental Health Report, June 9, 1999, Opening Session of the NMHA Annual Conference