From: Submission to the Select Committee on Mental Health and Addictions. Presented by Paul Garfinkel, June 3, 2009.
Ontario needs to target its program planning and funding allocations so that mental health and addiction programs are integrated where prevalence data indicates the highest need, e.g., young adults and those with personality disorders.
There is a wide range of clinical, sociological and cultural factors that bring the fields of mental health and addictions together. From a medical perspective, substance use disorders are a distinct category within the Diagnostic and Statistical Manual of Mental Disorders (DSM). Mental health and addictions are both rooted in a complex and variable combination of biology, genetics, and life experience – particularly exposure to stress and trauma. This means that many of the clinical skills used to treat mental health problems and addictions are similar. But the single most compelling reason for promoting greater integration of mental health and addiction services is the significant number of people who experience both a mental health problem and a substance use disorder.
Prevalence rates for concurrent disorders vary by methodology, but all estimates are high enough to warrant significant attention. Data from Statistics Canada’s Canadian Community Health Survey (CCHS) (2002) suggests that those with a substance use disorder are twice as likely to have a mood or anxiety problem (Rush et al., 2008). It is also true that persons diagnosed with a mood and anxiety disorder are twice as likely to suffer from a drug use disorder. In another study, 43% of individuals with a 12-month substance use disorder have a diagnosable mental health problem (Kessler et al., 1996). National epidemiological data from the US shows that 55% of individuals with a lifetime alcohol use problem and who have sought help for their addiction had a lifetime mental disorder (Regier et al., 1990). The likelihood of having a substance use disorder was four times higher for those with schizophrenia than for the population at large, and those with bipolar disorder were five times more likely to develop these problems.
More significant than the number of people with concurrent disorders is the experience of persons with concurrent disorders. These stories provide an impression of inadequate care, dissatisfaction with the care received, and difficulty in navigating a system of supports. Canadians with concurrent disorders are more likely than any other category of substance users to seek care (Ross, Lin & Cunningham , 1999), yet are four to seven times more likely to report unmet need than those who have one of a mental health or substance use problem (Urbanoski et al. 2007). Statistically, they also report low satisfaction with care (Urbanoski et al. 2007).
The acuteness and severity of concurrent disorders should also be recognized. In this area, as well, empirical data and the experiences of individuals and their families are mutually reinforcing. In terms of economic cost, there is strong evidence that the cost of care for one person with a concurrent disorder is greater than the cost of care for two people that each have one of mental health or addiction problem. One study that tracked health and social costs found that per person hospital costs for the individual with mental disorder were $390; for a person with substance use disorder were $344; for the person with concurrent disorders were $1485 (Somers, Carter & Russo, 2007). The welfare costs per person for those with a mental disorder alone were $480; for a substance disorder alone, $1246; and for a co-occurring disorder, $3348 (Somers, Carter & Russo, 2007)). In both health care and social service settings, having a co-occurring disorder was strongly associated with antisocial and challenging behaviour, legal involvement and risk of suicide or self-harm (Rush & Koegl, 2008). The complexity in providing care and support is likely related to the fact that rates of substance use disorders are particularly high among particular subpopulations of those with mental health problems, including young adults with personality disorders (Rush & Koegl, 2008; Grant, et al., 2004), the homeless (Farrell, Howes, Taylor et al., 1998), those involved with the criminal justice system (Abram & Teplin, 1991), and people with a history of sexual or physical abuse (Kendler, et al., 2000; Malinosky-Rummell & Hansen, 1993). The existence of a mental health problem significantly reduces the efficacy of substance use treatment, as these clients have rates of relapse far higher than the average.
Across North America, the fields of addiction and mental health developed in ways that have been surprisingly distinct from each other, given the overlapping and related nature of the diagnoses. The success of the self-help movement (particularly Alcoholics Anonymous) contributed to the rejection of addiction as a medical/psychiatric problem, since AA typically embraced mutual support and eschewed physicians and the pharmacological treatment of addictions. As a result, those who care for persons with both mental health and addictions problems were left with this dilemma: while rates of concurrent disorders are high – and as scientific literature increasingly points to the related etiology of mental health and addiction problems – the cultures of mental health care providers and addiction care providers were historically distinct, if not hostile. From a health care perspective, this presents an example of care that is focused on the person providing the service, and not on the person whom the services are designed to assist.
This has been slowly changing over the past two decades. The evidence is clear that integrated support for people with co-occurring mental and substance use disorders are more effective than non-integrated treatment and support. The plea for greater coordination of care has been made by the Substance Abuse and Mental Health Services Administration in the US, and by Health Canada. The creation of the Centre for Addiction and Mental Health is both a result of this change, and a contributor to it. Since its inception, CAMH has made concurrent disorders one of its priorities. We have significant experience in addressing the system integration and system capacity needs with respect to concurrent disorders.
The experience of CAMH and other integrated services provides important case studies of the mechanisms of integration, and the priorities. Administrative integration can be successful, but even the smoothest administrative collaboration is no guarantee of improved services. The tools for improving services are predominantly practical ones relating to assessment tools and service system collaboration. The success of integration should be assessed based on the experience of clients, not planners.
No service system can encompass all the needs of people with either mental health or addiction problems, or both. But we know that – across all areas and types of services – we require a targeted and strategic approach to integration that focuses on particular subpopulations. The prevalence and the consequences of concurrent disorders – the health system and beyond – requires us to focus on the severity and complexity of the problems faced by people needing assistance. Epidemiological data should be strengthened, and used to plan integration activities. Areas of acute need for integrated services include young adults (particularly those with personality disorders), people who are homeless, people with a history of sexual or physical abuse, and those with criminal justice histories.
In the last few years, as the Local Health Integration Networks (LHINs) have become operational, there has been much attention paid to service integration. The mental health and addictions system is under increasing pressure to coordinate and integrate services through partnerships and networks. Given what we know about the experiences of those with concurrent disorders, it is crucial that these efforts are targeted to populations with the greatest need, and that the underlying objective is to improve access to and the quality of services for those with both mental illness and addictions.
In Submission to the Select Committee on Mental Health and Addictions:
- Executive Summary
- The Centre for Addiction and Mental Health (CAMH)
- Mental Health and Addictions – Out of the Shadows
- Foundations of a Mental Health Strategy
- Key Components of an Integrated System
- Bringing it together