Toward a New Model of Care: Integrating Mental Health, Substance Use, and Somatic Care

1. Effects of comorbid substance abuse, specifically alcohol and tobacco smoking

2. Unhealthy lifestyle, related to a lack of health literacy and the failure of health promotion initiatives to target this vulnerable population, among which there may be a reduced ability to understand the need for behavioral changes

3. Underdiagnosis and under-treatment of somatic disorders among people with mental illnesses

4. Iatrogenic morbidity, i.e., obesity, cardiovascular diseases, and diabetes due to the adverse effects of psychotropic medication (Manu et al. 2014)

5. Common genetic risk factors for psychiatric and somatic disorders (Hansen et al. 2011)

25.5 Recovery: Outcomes of Real-life Importance

To date, most studies exploring the effectiveness of treatments for patients with dual disorders have used rather traditional outcome variables, such as abstinence from substance use and a reduced severity of psychiatric symptoms. However, it is increasingly evident that outcome variables need to reflect much more than just psychiatric symptoms, especially with chronic, complex disorders. Indeed, given the chronicity and continuous risk of relapse that these disorders entail, it might be much more valuable for patients to achieve gains in other aspects of their lives, such as obtaining good housing and work situations. Furthermore, users of the mental health system (patients, clients) in many countries have lodged strong objections against the existing mental health system, indicating that their treatment professionals’ goals of symptom stabilization do not correspond to their aspirations for recovery (Drake and Latimer 2012). Although very different for each individual, recovery typically encompasses opportunities for education, work, independent living, and community participation. Based on this view of recovery, service users argue that they want to play a more meaningful role in decisions regarding their care and in the delivery of services.

Focusing on outcomes relevant from the recovery perspective is a meaningful approach to the treatment of patients with dual disorders. In an interesting 10-year longitudinal follow-up study, Xie and colleagues identified their outcome variables in collaboration with their patients through a shared decision-making process (Xie et al. 2010). They established six domains of interest to both patients and care providers: (1) control over psychotic symptoms; (2) remission of problematic substance use; (3) independent living; (4) competitive (paid) work; (5) social contact with non-substance users; and, (6) general quality of life. A 3-year integrated outpatient treatment program produced improvements in all domains for a majority of patients. Interestingly, these changes occurred during the active treatment phase and continued to occur during the posttreatment follow-up phase. This suggests that making positive changes in areas that the patients themselves consider important might stimulate further growth and recovery, even after active treatment. Engaging patients and caregivers in a process of shared decision making with respect to treatment goals and service delivery has proven to be effective in both reducing substance use and increasing patient autonomy (Joosten et al. 2009, 2011).

Employment has become a central goal of mental health treatment for patients with serious mental illnesses. Indeed, improved psychiatric and substance use symptom severity, autonomy, and quality of life on the one hand, and highly significant reductions in healthcare service use and related costs on the other hand, are associated with steady employment among patients with dual disorders (Bush et al. 2009; McHugo et al. 2012). Thus, helping patients achieve competitive employment should be a prime goal with integrated treatment delivery. However, it is important to note that some programs need to be tailored to the patient. Recently, in a large European study, Knapp and colleagues showed that an Individual Placement and Support (IPS) program is a promising approach to establishing patients in paid employment (Knapp et al. 2013). In this study, IPS produced better outcomes than alternative (standard) vocational services, at a lower overall cost to the healthcare and social service systems. This pattern also held true for five of the six European sites when each site was analyzed separately, indicating that this approach can be implemented within different treatment systems and cultures. Compared to standard vocational rehabilitation services, IPS is therefore probably a cost-saving, cost-effective way to help patients with severe mental health problems secure and retain competitive employment.

Finally, safe, high quality housing is of great importance for patients to sustain positive life changes. However, this is currently one of the most difficult goals to achieve. Given the enormous increase in housing prices in most European countries, housing that is affordable for people who have low socioeconomic profiles, as do the majority of patients severely affected by dual disorders, is extremely limited. This shortage leads to hospitalizations, lengthens hospital stays, and increases the use of homeless facilities. Given the immense pressure in many European countries to drastically reduce in-patient capacity, safe housing is increasingly becoming a major problem. Patients with dual disorders in particular tend to find housing problematic. Indeed, sheltered housing facilities organized within the healthcare system are still largely “full abstinence” oriented, filtering out the most severe—and the most needy—patients.

For a long time, abstinence was the one and only goal of addiction treatment. Today, however, decreasing the amount of alcohol consumed in order to reduce high-risk drinking behaviors is an accepted treatment goal for many clinicians and some of the most influential agencies, such as the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the U.S. and the European Medicine Agency (EMA) (van Amsterdam and van den Brink 2013). The results of a randomized controlled trial have recently been published showing that patients with alcohol dependence can learn to reduce their drinking by taking nalmefene (not currently registered in the USA) and participating in a motivational and adherence-enhancing psychosocial intervention (i.e., the BRENDA model). Interestingly, the placebo control group in the BRENDA trial also demonstrated considerable reductions in the number of heavy drinking days and the total amount of alcohol consumed, suggesting that patients can change their alcohol use without a verum medication if they are motivationally supported (Mann et al. 2013). Harm reduction as a treatment strategy has been accepted for drug dependence for many years. The insistence on abstinence caused more harm than good, because many young drug-dependent patients did not succeed in remaining abstinent, which cost them their jobs, their homes, their health, and eventually their lives. Heroin-assisted treatment trials showed that providing heroin on a regular and externally controlled basis brings addicted patients back into treatment and helps them progress toward a higher quality of life (Fischer et al. 2007). Unfortunately, research on the controlled use of alcohol and/or drugs has not been conducted among patients with dual disorders, because studies on controlled substances usually exclude patients with a psychiatric comorbidity. Many of the studies reported throughout this book have shown that patients can obtain improved psychiatric and social functioning outcomes even if they continue using substances. It seems that improvement is possible, as long as the consumption of substances can be reduced and stabilized using external approaches (e.g., heroin-assisted treatment, methadone treatment) and/or internal behavioral management (e.g., controlled drinking). This is a promising observation that might encourage researchers to develop treatments that are open to a variety of substance use goals.

25.6 It Is All About the Money

In most countries, there is typically a great deal of tension between the need for mental health care and the amount of money that society effectively spends on it. There is also a great deal of variation between countries. The proportion of total health expenditures that is allocated to mental health care range from as low as 3 % in Poland to 13 % in the UK, with a mean of about 5–6 % in Western Europe. In comparison, 5–12 % of health expenditures are devoted to behavioral health in the USA and 7.2 % in Canada (Frank et al. 2009). Financial constraints, partly due to the economic crisis in Europe, have forced most countries to either reduce their mental health expenditures (e.g., the Netherlands) or to increasingly force program developers to take into account the health economics or cost–benefit aspect of care delivery.

Unfortunately, a sizeable proportion of patients with dual disorders belong to the category of patients with the highest treatment costs. Indeed, they are often among those with multiple, severe psychiatric and somatic illnesses, the greatest amount of disability, and the least family or community support; they also need the highest level of treatment integration, rehabilitation, and support services. Providing comprehensive, fully integrated care to these individuals is expensive. However, studies focusing on health economics increasingly show that this investment not only mitigates personal suffering but may also be no more costly when organized efficiently; in addition—and most importantly—this approach avoids shifting the costs to families, communities, and the criminal justice system (Larimer et al. 2009). Even less intensive interventions, such as contingency management (CM) aiming to reduce substance use in patients with severe psychiatric illnesses, can have substantial cost-reducing effects (e.g., fewer emergency hospitalization days) (Angelo et al. 2013; McDonell et al. 2013). Depending on the individual’s symptom severity level and related impairments, creative combinations of different therapeutic approaches are likely needed to meet the specific needs of patients with comorbidities; for example, a severely affected patient with schizophrenia and substance abuse may require motivational interviewing (MI) + CM + CBT + pharmacotherapy, while a less-impaired patient with an anxiety disorder and substance abuse may require fewer interventions (Kelly et al. 2012).

Final Considerations and Conclusions

Where should we be going in Europe? First, a major challenge for many (all) European countries is to provide adequate human resources to deliver essential mental health interventions. There are major differences between European countries in terms of national income, and, closely related to this, the health resources that are available. The proportion of national resources being invested in mental health vary widely between countries, reflecting different political priorities, but also cultural differences in attitudes and even levels of stigma toward individuals with mental health problems. In many countries, patients with dual disorders are particularly affected by stigmatization and a lack of appropriate services. In addition, it has been suggested that the economic crisis, which has most severely affected southern European countries, has had a major, negative impact on both the prevalence and course of severe, complex psychiatric problems (Anakwenze and Zuberi 2013). In particular, when combined with early childhood adversity, poverty is associated with an increased risk of both the onset of substance use and the transition toward substance abuse (Benjet et al. 2013). Political action is needed to stimulate a reappraisal of the way mental health expenditures are allocated in order to alleviate the consequences of the economic burden, at least for the most vulnerable families.

An important factor underlying the lower quality of care for patients with dual disorders is the separation between mental healthcare services, addiction services, and somatic-medical services. Different organizations, different types of professional caregivers, different educational backgrounds, and differences in funding and insurance regulations reflect this separation. Thus, the most important goal for Europe would be to mandate equal parity between mental health care (including substance use disorders) and somatic health care in every country, if possible under European guidance. Indeed, the editors sincerely hope that, throughout the different chapters in this book, it has been obvious to readers that this separation should be considered archaic at the current stage of development of psychiatric care, doing (much) more harm than good. The high prevalence of patients with dual disorders within all care systems, with their multiple needs, underscores the urgent need to achieve a fundamental integration of these different care systems. This will make it possible to improve the quality of care and efficiency of care delivery, ultimately with an overall better cost–benefit ratio (Dewa et al. 2009; Hoch and Dewa 2014).

Collaborative care requires integrating a wide variety of services (e.g., somatic care, housing, work-day activities) and adopting a patient-focused approach that links these services to the specific needs of each patient, whenever and wherever the services are needed; for example, when patients are hospitalized for severe somatic complications, this can be an excellent opportunity to engage them in psychiatric and/or substance use treatment. Care systems need to be reorganized in order to make this collaborative process available. Both the mental health and addiction treatment systems need to increase their capability to handle the multiple needs of patients with dual disorders. To enhance this process, practical European guidance mechanisms need to be developed. In addition, within the training curricula of the different mental health professions, more focus needs to be placed on the management of patients with multiple, complex problems. Indeed, most current training programs and clinical guidelines focus on the management (diagnosis, treatment) of single, specific disorders. This contrasts with the clinical reality and the needs of most patients with dual disorders, as well as with the collaborative care approach.

To conclude, research, training programs, and guideline development efforts have focused on reducing psychiatric symptoms, as defined by the DSM or ICD, as the ultimate outcome goals. There is a clear need for a European consensus that, for patients with complex dual disorders, outcome needs to be more broadly defined; the new target outcomes need to include not only a reduction in psychiatric and addiction symptomatology but also—and most importantly—variables reflecting a reconnection with and reintegration into society (e.g., housing, work-day activities), as well as subjective improvements identified by the individuals themselves (e.g., quality of life, self-esteem, and shared decision making in the treatment processes). Indeed, it is the latter category of targets that empowers patients with dual disorders to achieve sustainable change.

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