Fig. 4.1
Severe addiction and mental illness (SAMI) based on population and in the system of care; NCS National Comorbidity Survey (Kessler and Merikangas 2004)
So if you move from milder symptoms not in need of acute or emergency care (level in front) towards a crisis and the need for acute care (level in the back) the complexity of symptoms increases, concurrent disorders become the rule and not the exception.
4.2.2 Special High Need Populations
Patients with addiction and concurrent mental disorders form part of very different populations with all levels of social functioning. This is resulting in varying additional support needs, access to care and treatment options. Due to different social and health-care systems it is important to acknowledge these subpopulations with specific challenges for the system of care and society as a whole in both North America and Europe.
The ongoing First Nations and Native American health-care crisis (Krausz 2008; Spittal et al. 2007) is specific to North America. The indigenous population is in an especially critical state due to bad living conditions on reserve, social marginalization, and extreme levels of trauma, substance use, and lifestyle-related physical illness such as metabolic syndrome and obesity, with little or no health care available in their communities. They are also overrepresented in all particularly marginalized groups as homeless, in foster care, or early imprisonment. The prevalence of complex concurrent disorders is much higher than elsewhere in the society (Spittal et al. 2007).
Vulnerable urban populations (Krausz et al. 2013; Linden et al. 2013), including those living in substandard housing or homeless, are typical for large metropolitan areas. In large cities, poor neighbourhoods, like Vancouver’s Downtown Eastside, are of special concern. They are known for extreme levels of harmful substance use, trauma, and mental illness (Krausz et al. 2013), and difficulties in provision of appropriate care due to the housing situation. That was the reason for a National research demonstration project in Canada, the At-Home—Chez Soi project (Goering et al. 2011), exploring housing and support for mentally ill homeless in five Canadian centres. It demonstrated that “housing first” with appropriate community support enables recovery even of severely affected dual disorder patients (Schutz et al. 2013).
Migrants arriving in a new country are often amongst those listed as a vulnerable group. Language barriers, traumatic experiences, and insecure legal status can further complicate access to any support. In Canada and the USA, migrants in this category form a subpopulation nearly excluded from formal health care (Kluge et al. 2012). Even those able to access the systems have difficulties finding culturally appropriate programmes. In Vancouver, nearly 50 % of the people are of Asian origin, and in California Spanish has become the dominant language.
In Europe, other regionally differing cultures are suffering from exclusion, foremost those of African origin or individuals from the former Soviet Union member states and their political satellites. Even though there are specific programmes for migrants, they often suffer from the separation of treatment systems for substance use and mental health. This can lead to exclusion of patients with substance use in the case of psychiatric centres, or exclusive psychosocial support lacking medical assistance where services are provided by social workers in specific multicultural drug-counselling units.
4.2.3 Stigma and Marginalization in the System of Care
Addiction and mental illness are arguably the most stigmatized and structurally discriminated conditions in health care worldwide. The burden of disease particularly among young people is among the highest of all medical conditions and still growing, and the mortality is huge. Despite these stark facts, compared to other areas of health care, mental health and addiction remain the most underfunded area of medicine (Livingston et al. 2012).
4.2.4 Culture of Care
Stigma, poverty, homelessness and social marginalization, and substance use, mental and physical comorbidities form a vicious circle. Combined with the lack of specialized services these patients are frequently not in any regular mental health-care programmes. Consequently, these people often tumble from crisis to crisis and use ERs as their only access to care.
ERs in North America are often overcrowded and have little to offer in terms of treatment. Moreover, ER’s are not funded or equipped to replace community services, especially for high need patients with complex concurrent disorders.
If families in North America can afford private treatment programmes, either residential or community based, a range of specialized providers are available. Particularly university-affiliated clinics offer standardized programmes (Savage et al. 2007; Torchalla et al. 2012) with proven effectiveness. But overall, these are neither accessible nor affordable for the average patient and relevant only for a small minority.
With structural and funding problems in European countries similar trends can develop. Nevertheless clinical pathways and a coherent approach to care are far more common in Europe. Particularly effective are established pathways in the Netherlands with stepped care approaches (Schippers et al. 2002) or Switzerland and Germany (Wienberg 2001).
The Canadian culture of care is similar to the European system. However, while everybody has a right to be treated, the services needed for stepped care such as are mostly missing, so the ERs become the inefficient hub of triage and care.
So as shown in Fig. 4.2, ideally different levels and models should and could connect in clinical pathways (represented through the line), which unfortunately is often not the case. Even if the capacities are available, which is an exception, they are not integrated and connected.
Fig. 4.2
Levels of care
4.3 Treatment Paradigms and Goals
The last two decades have been dynamic in terms of paradigm shifts in the area of mental health and addiction. Nearly every essential concept from harm reduction over methadone substitution, and controlled consumption to abstinence based care was questioned and subject to national and international reviews (e.g. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) standards; Heroin assisted treatment (HAT); Harm reduction).
Substantial regional differences in best practice, especially in the treatment of addiction, significantly impact the treatment of dual disorders. The dominant paradigms changed in Europe as well as in the USA and Canada as a result of drug policy under pressure, the response to the HIV epidemic, and the obvious failure of the abstinence focused system of care.
In psychiatry, the neglect of substance use of patients with severe persistent mental illness in treatment undermined psychosocial treatment programmes and lead to low retention and compliance in the hospitals as well as community care. Single programs such as those in Dartmouth, USA (Alterman 1985; Drake et al. 2008), Hamburg, Germany (Krausz and Müller-Thomsen 1994) or Bern, Switzerland (Moggi et al. 2002) or Antwerp, Belgium (Morrens et al. 2011) started to address treatment of comorbid disorders, in particular of psychosis and addiction.
One of the most important lessons of the last decades is that treatment capacity, funding, best practice, and health politics are not only influenced by evidence but also and sometimes foremost by economic considerations and political priorities. Even drastic mortality rates and high public health risks are not per se a reason for most governments to respond. On the other hand, the implementation of harm reduction programmes as well as heroin-assisted treatment is demonstrate the major impact of clinical innovation. They saved thousands of lives, prevented life-threatening infections such as HIV and supported recovery on a large scale.
4.3.1 Harm Reduction
Why is the harm reduction paradigm of any relevance to the treatment of patients with mental illness and severe substance use? There are three reasons:
1.
Due to their risk behaviours comorbid patients are very vulnerable to severe infections and physical harm (Dausey and Desai 2003) and need protection and support.
2.
For those with dual disorders, access to the system is more complicated due to system thresholds, social marginalization, and homelessness but also due to some clinical disabilities like cognitive impairments. In the BC Homelessness survey we showed, that the sicker patients were, the more difficult it was for them to get appropriate support (Krausz et al. 2013). Harm reduction programmes are an important entry point to connect to mental health or addiction care.
3.
Harm reduction is one of the oldest medical principles and the common ground for treatment approaches beyond. Without survival, prevention of physical harm and trauma, any recovery may be impossible. When the “harm” in harm reduction is defined a little wider than just AIDS, e.g. by including social deterioration, deprivation or criminalization, then it becomes obvious that this is a prerequisite for any further step. The identification of dual disorder patients along with provision of psychiatric services in harm reduction facilities would be “low threshold” indeed. An example of such an intervention is the provision of opioid maintenance treatment (OMT) in safe injection facilities established in some Swiss cities today.
The US government and its funding agencies have only recently opened up to “harm reduction” strategies and approaches. Until the Obama presidency “harm reduction” was more of a “non-word”, which might well have influenced the decision of the National Institute of Drug Addiction (NIDA) to withhold funding or any other support from programmes pursuing such harm reduction approach.
Canadian provincial governments, which are in charge of health-care legislation and organization, took a different route, sometimes in conflict with the Federal government in Ottawa. The only official “safe injection site” in North America today, opened in Vancouver backed by the provincial government in British Columbia (BC). Insite in Vancouver is still questioned and legally battled by the conservative Canadian federal government (Wells 2011), despite needle exchange and similar low threshold programmes being widely accepted since the HIV epidemic.
In Europe, harm reduction strategies were implemented first in Switzerland, Germany, and the Netherlands in the 1980s with a lag of about 10 years in the southern European states as Spain, Italy, and Greece. This led to up to tenfold differences in the HIV prevalence rate between states. For example in Hamburg, the prevalence rate is about 3 % but in Barcelona about 30 % (EMCDDA 1999). The joint EU guidelines on harm reduction are the result of that experience. Even fierce opponents of harm reduction changed their approach based on an unfortunate “natural public health experience” with hundreds of thousands infected and dying of HIV despite knowledge of what could help to prevent it.
4.3.2 Abstinence and Controlled/Moderate Use
Internationally, most mental health programmes for the treatment of comorbid patients are based on abstinence as treatment prerequisite and certainly as a treatment goal. This is based on the conceptual understanding that substance use including alcohol and cannabis can trigger psychotic symptoms or mood swings. In most Canadian and US health-care institutions, supported housing and other social services, even moderate substance use is unacceptable. Noncompliant patients are either forced to abstain through certification or seclusion, or are denied access to care (e.g., in residential care settings). With this approach the most vulnerable urban populations with complex concurrent disorders and long histories of severe substance use are again excluded from care and social support.
Related posts:
Evolution of Mental Health and Addiction Care Systems in Europe
Bipolar Affective Disorders and Alcohol Dependence: Comorbidity, Consequences, and Treatment
Schizophrenia and Addiction
Personality Disorder and Addiction
Mood Disorders and Addiction
Psychiatric Comorbidity in Heroin Maintenance and Methadone Maintenance Treatments
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