National Alliance on Mental Illness
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December 3, 2002

SAMHSA Issues Report on Co-Occurring Mental Illness and Substance Abuse Disorders to Congress

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) this week issued their long anticipated report to Congress on treatment services for individuals with co-occurring mental illness and substance abuse disorders. This new SAMHSA report is expected to provide important new guidance to the states on how they can use existing programs to invest in evidence-based practices designed to meet the needs of individuals with co-occurring disorders. However, the report stops short of recommending changes to the federal mental health and substance abuse block grants that would create additional incentives for recipients of these funds to treat people with co- occurring disorders.

The SAMHSA report, mandated by Congress in 2000, contains 5 major sections including: a comprehensive review of the scientific research on treatment and prevention of co-occurring disorders, a description of how states currently serve individuals with co-occurring disorders, details of the efforts by SAMHSA and the states to develop innovative programs and a new five-year action for SAMHSA on this critical public health priority.

In particular, the report describes the numerous barriers that have limited the ability of both the substance abuse and mental health systems meeting the needs of this population -- focusing on how inflexible funding streams and lack of capacity have left individuals unable to access effective treatment. The report also notes that evidence-based service models exist, including recovery- oriented integrated treatment for mental illness and substance abuse within coordinated and organized systems and treatment settings (including service coordination based upon the severity of both disorders).

This new report, entitled "Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders" can be accessed at:

View NAMI's written imput to SAMSHA  made during the development of this report

Role of SAMHSA’s Block Grant Programs Detailed

This report was mandated by Congress as part of federal legislation passed in 2000 reauthorizing SAMHSA. At the time, mental illness and substance abuse advocates engaged in a major debate about the role of separate federal substance abuse and mental health block grants in helping states serve individuals with co-occurring disorders. For its part, NAMI argued vigorously in favor of granting states greater flexibility to blend funds from these separate block grants to finance integrated treatment free of cumbersome and separate reporting and accounting requirements for each block grant. Under intense pressure from interests representing substance abuse agencies and providers, Congress did not grant SAMHSA and the states this authority. Instead Congress ordered SAMHSA to develop this report. Intense pressure from the substance abuse interests has continued, giving SAMHSA little room to come forward with a strong recommendation for greater authority for states to blend dollars from the separate Block Grant programs.

As a result of this limitation, this report recommends a new SAMHSA-funded incentive grant program on co-occurring disorders to help enhance state infrastructure and treatment systems. Such a program would require new and additional funds from Congress (unlikely in the current budget environment), rather than from current Block Grant funding. NAMI is disappointed that the report does not address barriers in the existing block grants and will continue to advocate for more flexibility in the block grants to pay for integrated treatment for individuals with co-occurring mental illnesses and substance abuse disorders.

Despite this limitation, this report does contain some important new guidance and information for the states.

First, the report includes a comprehensive review of the existing clinical and services research demonstrating that integrated treatment is effective in achieving better outcomes than models that rely on uncoordinated parallel and sequential services.

Second, with regard to the use of Block Grant funds, the report notes that "nothing in the reporting or accounting requirements precludes programs from using Block Grant funds to provide integrated treatment for co-occurring substance abuse and mental disorders." And, the report provides descriptions of how certain states are already financing integrated treatment.

Further, the report declares that SAMHSA can provide "technical assistance and promote peer assistance to States to ensure that these...requirements do not present an undue barrier to providing a full array of services, including integrated treatment..." NAMI is hopeful that this report will provide the direction needed to push more states to invest federal Block Grant dollars into integrated treatment programs.

The report also emphasizes that SAMHSA intends to elevate treatment and prevention of co-occurring disorders as a major priority. This includes a new five-year plan for the agency to assist states in improving outcomes for individuals with co-occurring disorders by improving access to evaluation and treatment in both systems to ensure that "any door is the right door." SAMHSA also intends to move toward helping states develop seamless systems designed to foster early intervention, treatment and follow-up care based upon evidence- based practice.

As part of this effort, the report recommends establishment of a national co- occurring disorders prevention and treatment technical assistance and cross- training center at SAMHSA and increased federal agency collaboration (particularly with the National Institutes of Health and the Centers for Medicare and Medicaid Services) to enhance research attention and funding on co- occurring disorders.

Background on Co-Occurring Disorders

According to 1999 Surgeon General's Report on Mental Health, 51 percent of individuals with one or more mental disorders have a lifetime history of at least one substance abuse disorder. The Surgeon General's Report also noted that individuals experiencing these disorders simultaneously have particular difficulty receiving diagnostic and treatment services, despite the fact that these disorders are very treatable. Research has demonstrated that if one of the co-occurring disorders goes untreated, then both usually get worse and additional complications arise with poor responses to traditional treatment and increased risk of other serious medical programs, suicide, criminalization, homelessness and separation from family and community.

Despite the enormous challenge that this population poses for both the mental health and substance abuse systems, significant progress has been made in the development of evidence-based interventions and programs with a demonstrated record of success in improving outcomes. Unfortunately, states and communities have been slow to adopt these practices -– the result (as this new SAMHSA report demonstrates) of lack of coordination among services systems, complicated funding streams, stigma and barriers related to clinical staff licensure and training. These barriers are best overcome when public agencies representing both the substance abuse and mental health service systems adopt multi- disciplinary integrated models that treat both disorders simultaneously. These recovery-oriented integrated treatment programs have a demonstrated record of success in achieving superior outcomes and reduced relapse for both disorders.