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Many patients present a clinical situation in which psychiatric symptomatology and substance related symptomatology are inextricably intertwined. A paradox exists for these patients, in that both the addictions and mental health systems of care, and the level of care assessment methodologies associated with each system, are designed for one type of disorder only, or only one disorder at a time. As a result, these individuals are perceived as 'system misfits.' Our inability to assess these patients accurately and place them appropriately contributes to poor outcomes and high costs. These costs consist of expensive utilization of scarce system resources. There is a growing need for a more integrated methodology for level of care assessment, in which both psychiatric and substance symptomatology can be assessed simultaneously to generate a wider array of programmatic interventions for individuals with co-occurring disorders. This article describes efforts to build upon the Patient Placement Criteria published by the American Society of Addiction Medicine, Second Edition (ASAM PPC-2) to develop a revised instrument that is much more capable of evaluating the placement needs of individuals who present with combinations of psychiatric and substance symptomatology. [ABSTRACT FROM AUTHOR]

This article describes research-based principles of successful treatment interventions in individuals with co-occurring disorders. These principles are placed in the context of an integrated model of service delivery that utilises a common language or treatment philosophy that makes sense from the perspective of both mental health treatment and substance disorder treatment fields. The article begins with an overview of the clinical and programmatic dilemmas faced by clinicians in treating these ‘dually diagnosed’ individuals and then enumerates 7 principles of treatment. These are: dual diagnosis is an expectation, not an exception, within any of the 4 subtypes of comorbidity (using a subtyping model based on high/low severity of each disorder); the most significant predictor of treatment success is the provision of an empathic, hopeful, continuous treatment relationship in which integrated treatment and care coordination are provided over time; within the context of this relationship, caretaking and case management are balanced with empathic detachment, empowerment and confrontation at each point in time; within this ongoing treatment context, both mental illness and substance disorder are considered primary, and integrated dual primary treatment is provided; both mental illness and addiction are examples of not just random primary disorders, but chronic biological mental illnesses which can be understood using a disease and recovery model; the model defines parallel phases of recovery, which themselves define phase-specific treatment interventions; as a result, there is no single correct intervention in this model. For each individual, the correct treatment must be matched to subtype, diagnosis, phase of treatment and extent of patient motivation and disability; and within a managed-care system, these interventions must be further individualised by a discrete level of care assessment for each disorder. These principles provide a template both for developing practice guidelines to determine individualised clinical treatment matching, as well as providing a template for large-scale system initiatives for the creation of comprehensive continuous integrated systems of care, and for assigning roles for each type of programme within those systems. These large systems initiatives are currently underway in several US states, and provide a laboratory for further research on this model. [ABSTRACT FROM AUTHOR]

Competing Interests: The author reports no financial relationships with commercial interests.

During the postcrisis period, many individuals struggle to transition to available care, often falling through the cracks. This article discusses effective postcrisis approaches that provide rapid access to transitional team-based care using critical time intervention strategies. It also highlights the development of state, county, and funder models for "care-traffic control" to ensure swift linkage to follow-up services, along with new funding models that support intensive community crisis stabilization during the postcrisis period. Emerging crisis systems can leverage these emerging services and approaches to facilitate successful transitions for individuals in need., Competing Interests: Disclosure Outside of this work, Dr R.O. Cotes has received research funding from Alkermes, Ireland, Karuna, Otsuka, Japan, and Roche, Switzerland. He is a consultant to the American Psychiatric Association and Saladax Biomedical, and a speaker for Clinical Care Options. The remaining authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This work expands on the National Council for Mental Wellbeing whitepaper Quality Measurement in Crisis Services. The authors present 2 approaches to measure development: The first maps flow through the crisis continuum and defines metrics for each step of the process. The second uses the mnemonic ACCESS TO HELP to define system values, from the perspective of various stakeholders, with corresponding metrics. The article also includes case examples and discusses how metrics can align multiple components of a crisis system toward common goals, strategies for using metrics to drive quality improvement initiatives, and the complexities of measuring and interpreting data., Competing Interests: Disclosure J. Parks is consultant to Boehringer-Ingelheim. B. Shaw is an employee of the United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration. This article does not represent an official position or opinion of the United States Department of Health and Human Services. Other authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The comprehensive health care integration (CHI) framework promotes the delivery of integrated physical and behavioral health care to adults and children in community settings by providing a flexible integration approach for both physical and behavioral health settings, including ongoing measurement of outcomes linked to payment methodologies. The CHI framework demonstrates value, strengthening alignment between provider organizations and payers to support service integration at implementation and on an ongoing basis., Competing Interests: Dr. Chung has served as an adviser for Valera Health and McKinsey & Company and as a consultant for Otsuka Pharmaceuticals. Dr. Minkoff was a paid consultant to the National Council for Mental Wellbeing’s Center of Excellence for Integrated Health Solutions for the work done on this column. The other authors report no financial relationships with commercial interests.

People with co-occurring mental and substance use disorders experience poor outcomes and incur high costs in multiple domains. Efforts to develop and disseminate evidence-based integrated programs for people with such co-occurring disorders began to wane in the past decade as efforts shifted toward integrating primary health care. Several recent trends underscore the need to refocus efforts on providing integrated care for people with both mental and substance use disorders. The authors summarize what is known about integrated care for people with these co-occurring disorders and recommend advancing implementation and research on integration and improving outcomes with existing resources.

A national dialogue on systemic racism has been reinvigorated by the highly publicized deaths of several unarmed Black Americans, including George Floyd and Breonna Taylor. In response, the AACP Board considered how to promote concrete, meaningful action to support its membership in measurably addressing structures and policies that promote racism. In this article, literature on existing frameworks aimed at addressing health inequity on the organizational level are reviewed. We introduce the Self-assessment for Modification of Anti-Racism Tool (SMART), a quality improvement tool that aims to meet the AACP's needs in facilitating organizational change in community behavioral healthcare. The AACP SMART's development, components, use, and future directions are described. The AACP SMART builds on prior organizational tools supporting equity work in healthcare, providing a quality improvement tool that incorporates domains specific to structural racism and disparities issues in community behavioral healthcare.

This paper represents a position statement of the American Association of Community Psychiatrists (AACP) regarding treatment plans. We regard treatment plans, a documentation requirement, in this position statement, as distinct from the process of treatment planning. The AACP is concerned that treatment plan documentation in its current state, creates unnecessary administrative burden for physicians, without evidence of benefit for patients, reducing direct patient contact time, thereby negatively impacting quality of care. In this position, we echo the statements made by the American College of Physicians in their position paper entitled "Putting Patients First by Reducing Administrative Tasks in Health Care". We recommend a review of the treatment plan documentation requirement across the nation, engaging consumers, providers, regulatory agencies in all states, as well as national reimbursement and regulatory agencies, in order to promote the process of quality driven care and documentation.

This article has described the CCISC model and the process of implementation of systemic implementation of co-occurring disorder services enhancements within the context of existing resources. Four projects were described as illustrations of current implementation activities. Clearly, there is need for improved services for these individuals, and increasing recognition of the need for systemic change models that are effective and efficient. The CCISC model has been recognized by SAMHSA as a consensus best practice for system design, and initial efforts at implementation appear to be promising. The existing toolkit may permit a more formal process of data-driven evaluation of system, program, clinician, and client outcomes, to better measure the effectiveness of this approach. Some projects have begun such formal evaluation processes, but more work is needed, not only with individual projects, but also to develop opportunities for multi-system evaluation, as more projects come on line.

Using an integrated theoretical framework, a continuous and comprehensive model system of care for dual diagnosis patients can be designed.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

This article describes the implementation and preliminary evaluation of a dual diagnosis case rate program developed as a collaborative experiment between a public managed Medicaid organization (MHMA) and a specialized integrated dual diagnosis provider (Choate) with a vertically integrated, managed-care oriented system of care. The case rate program applied to dually-diagnosed inpatient referrals for a period of 65 days. On admission, 68% of the patients had little insight, motivation and compliance regarding addiction or psychiatric management. Nonetheless, 56% maintained sobriety for 65 days, and 49% of these were still sober at 95-day follow up.

People with chronic mental illness present complex challenges for the design of health care financing reforms. In this position statement from the committee on psychiatry and community of the Group for the Advancement of Psychiatry, the authors describe chronic and severe mental illnesses as psychiatric illnesses that require acute and ongoing psychiatric assessment and treatment, as chronic medical diseases that require ongoing rehabilitative services, and as persistent disabilities that need ongoing supportive care and social services. Any proposal for health care reform must ensure parity of chronic psychiatric illnesses with other psychiatric conditions. It must also reimburse psychiatric rehabilitation at parity with other medical rehabilitation and provide equal access to and reimbursement for broad ancillary health services that reduce costs and improve quality of life.

Dual diagnosis of severe mental illness and substance disorder is a frequent and difficult challenge to the mental health and substance abuse systems. This chapter reviews the dual diagnosis problem and introduces the chapters that follow.

In this paper a group of knowledgeable individuals with expertise in psychiatric education present their recommendations for a basic psychiatric residency curriculum concerning the chronically mentally ill. The proposed curriculum consists of knowledge, skill, and attitude educational objectives, as well as clinical experiences, faculty supervision, didactics and seminars, and evaluation mechanisms. Recommendations are also made concerning changes in the Accreditation Council for Graduate Medical Education's Special Requirements for Residency Training in Psychiatry, which would require residency programs to place more emphasis on training to meet the needs of the chronically mentally ill. Obstacles to the implementation of the proposed recommendations are presented and possible solutions are discussed.

The emergence of the young adult chronic patient, and the attendant perception that deinstitutionalization has failed, may be viewed as the inevitable result of the success of deinstitutionalization. Deinstitutionalization gave freedom to the mentally ill, but in doing so it left patients free to struggle on their own. The deinstitutionalization ideology failed to predict the difficult clinical reality that most patients do not readily choose the identity of chronic mental patient and are reluctant to make use of available treatment programs. The author presents the key principles of a new postinstitutional ideology that focuses on helping patients attain the best possible adaptation to their illness regardless of the setting in which they are treated. He hopes the ideology will infuse new hope and clinical expertise into work with people with chronic mental illness.

In attempting to build a successful program for chronic patients at the Somerville (Mass.) Mental Health Clinic, the authors first found it necessary to uncover, address, and resolve six fundamental paradoxes engendered by deinstitutionalization that were stressful to mental health clinic staff and inhibited effective programming. The paradoxes involve issues relating to community mental health ideology, clinicians' sources of self-esteem and professional ability, and clinicians' views of chronicity and the deinstitutionalization movement in general. Resolution of the paradoxes requires major value changes, which can be brought about by effective clinical leaders who serve as role models and teachers, and who set the tone for patient care.

Innovative treatment programs can be implemented successfully in hospitals only if key actors take on leadership responsibility for the new programs. Implementation of an innovative Addictions Day Treatment Program (ADT) for alcohol and substance abusers in a 156-bed community hospital is reported. Implementation issues for staff psychiatrists, psychologists, psychiatric nurses, and hospital administrators are the primary subject of this article. Participation of these professional groups depended on their treatment ideology, the threat they perceived the program to be to patients, the time demanded of them, whether they would be reimbursed for providing care by the program, and the changes the program introduced in provider-patient interaction. The way shared responsibility among key hospital and unit leaders made it possible to overcome resistance to the program and to develop a positive consensus about day treatment is shown.

A model that integrates the treatment of patients with a dual diagnosis of psychosis and addiction has been developed on a general hospital psychiatric unit. The model emphasizes the parallels between the standard biopsychosocial illness-and-rehabilitation model for treatment of serious psychiatric disorders and the 12-step disease-and-recovery model of Alcoholics Anonymous for treatment of addiction. Dual-diagnosis patients are viewed as having two primary, chronic, biologic mental illnesses, each requiring specific treatment to stabilize acute symptoms and engage the patient in a recovery process. An integrated treatment program is described, as are the steps taken to alleviate psychiatric clinicians' concerns about patient involvement in AA and addiction clinicians' discomfort with patients' use of medication.

The authors describe seven paradoxes that confront psychiatric residents being trained in the psychosocial treatment of chronic schizophrenic patients in community settings. The paradoxes arise because the psychosocial framework necessary for working with such patients challenges the residents' strongly held beliefs and values concerning the nature of psychotherapy and of schizophrenia. The paradoxes result in stress and resistance to learning new approaches and must be clarified and resolved for training to proceed successfully. The authors examine the origins of the paradoxes and the reactions of residents to each, and describe how the supervisory relationships of the training setting can be used to resolve them.