Program components of a comprehensive integrated care system for seriously mentally ill patients with substance disorders.

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

Implementing dual diagnosis services for clients with severe mental illness.

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.

Innovations in integrated dual diagnosis treatment in public managed care: the Choate dual diagnosis case rate program.

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.

Ensuring services for persons with chronic mental illness under national health care reform.

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 major mental illness and substance disorder: an overview.

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.

A basic residency curriculum concerning the chronically mentally ill.

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.

An integrated treatment model for dual diagnosis of psychosis and addiction.

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.

Implementation issues in addictions day treatment.

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.

Beyond deinstitutionalization: a new ideology for the postinstitutional era.

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.

Paradoxes faced by residents being trained in the psychosocial treatment of people with chronic schizophrenia.

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.

Paradoxes in programming for chronic patients in a community clinic.

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.