Recommendations for Integrated Systems and Services for People With Co-occurring Mental Health and Substance Use Conditions

Continued improvement in services and systems for co-occurring mental and substance use disorders can build on what is already known about both services and implementation. A recent review (12) observed that interventions for substance use disorder that benefit people in the general population should be adapted to benefit also those with co-occurring mental and substance use disorders. These interventions may vary in intensity and duration and can be provided in multiple settings. Useful services may include integrated screening and assessment, integrated teamwork over time, integrated stage-matched interventions, integrated skill building, access to medications for both disorders, and integrated recovery support (13–15). Although integrated treatment ensures that mental and substance misuse services are available in the same setting and coherently delivered, the authors of the aforementioned review found that “while encouraging, results of trials . . . are equivocal, [and often] hampered by poor experimental design.” The authors also reported varying study methodologies, interventions, and outcome measures and noted a lack of accommodation to variations in “readiness to change, severity and type of illness and substance use” (12). Research methods that address implementation of integration clearly need to be enhanced.

Nonetheless, action is needed to apply what is likely to help improve integration. Integrated care embodies “no wrong door,” can improve access, person-centeredness, and equity and also increases the availability of treatment for both mental health and substance use conditions for this large, heterogeneous, and high-risk population. Consequently, because of anticipated high prevalence of co-occurring mental and substance use disorders in mental health settings (e.g., prevalence of substance use disorder among people with serious mental illness) and substance use disorder settings (e.g., prevalence of mood and anxiety disorders among people with opioid use disorder), programs and providers routinely need integrated skills and practice supports to help existing populations with co-occurring disorders. However, implementation of integrated services requires focused attention by system leaders. A recent technical assistance brief (13) and systematic review of the organization of community health services for people with co-occurring disorders (14) summarized evidence-based pharmacological and psychosocial interventions that likely are effective for people with co-occurring mental and substance use disorders, while noting that much more is needed to update implementation guidance for practitioners, programs, funders, and state systems.

Implementation of integrated services is facilitated when improvement efforts in co-occurring capability and workforce competency at the provider level are aligned with funding instructions, regulatory guidance, and provision of technical assistance from funders and regulators (13–15). However, part of the system can make progress on implementation when other partners are not yet engaged. Results from previous studies using implementation tool kits have indicated that progress in integrated service delivery can be embedded in any process, program, professional, or team providing care and in any policy, procedure, or payment instruction governing any single funding stream (7–10).

Efforts in CCBHCs, for example, illustrate both opportunities and challenges of implementation. CCBHCs are expected to provide comprehensive services for people with co-occurring mental and substance use disorders by providing or coordinating mental health and substance use treatment and providing medication treatment for addiction. In the first year, 84% of CCBHCs offered medication to treat people with addiction, compared with only 36% of programs nationwide (11). However, although CCBHCs reported an increase in the number of people receiving addiction treatment, no metrics or tools are available that delineate progress in delivering integrated co-occurring disorder treatment within either mental health or addiction services provided by CCBHCs.

Broader implementation of integrated services for co-occurring mental and substance use disorders may therefore benefit from efforts by state and local systems, in partnership with providers, employing strategies that previously have successfully aligned funding instructions and regulatory guidance with use of practice improvement tools and strategies by providers. Next steps for both systems and providers are described in the following.

With or without state- or county-level system efforts, provider agencies and programs can take steps to improve treatment of patients with co-occurring disorders. A recent systematic review of treatment guidelines indicated that much is known that can be implemented, even though there are still “certain important aspects . . . essential for treatment planning . . . [that are] not addressed by any guideline, including the specifics of a concurrent disorder framework, the ‘matching’ of treatment needs, and the evaluation or ‘staging’ of the severity” (15).

People with co-occurring mental and substance use disorders have urgent needs, and many are dying without receiving needed services. It is time for a national reprioritization of investment in consultation, training, technical assistance, and research on implementation of integrated systems and services for the “expected” population with co-occurring needs. In the meantime, systems and programs should use improvement strategies already shown to be potentially effective. Our hope is that our recommendations allow systems, funders, and individual providers to use existing resources to immediately begin making sustainable improvements in services that result in better outcomes for people with co-occurring disorders.