Integrated Treatment and Blended Funding for Co-Occurring Mental and Addictive Disorders
NAMI’s Position (summarized from the NAMI Policy Platform)
NAMI supports blending mental health, alcohol, and substance abuse funds at the state level for the treatment of persons with dual diagnoses of a brain disorder and co-occurring substance abuse. NAMI endorses integrated, rather than sequential or collaborative-parallel, treatment programs for persons with dual disorders of mental illness and addictive disorders.
NAMI Advocacy Goals and Strategies
One of the key federal programs supporting community-based services for individuals with severe mental illnesses is the Mental Health Block Grant (MHBG), officially referred to as the "Community Mental Health Services Performance Partnership Block Grant." This program is managed federally by the Center for Mental Health Services (CMHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA). The MHBG requires states to develop comprehensive services plans to persons with serious mental illness using the advice of state mental health planning councils, 51 percent of whose members must be consumers, family members, and non-treating professional citizens. Upon application approval, each state receives an annual allotment that provides funding for community mental health services to persons with serious mental illnesses. A separate block grant program at SAMHSA – the Substance Abuse Treatment and Prevention Performance Partnership – provides funding to the states for substance abuse treatment and prevention.
Over the past two years, the MHBG has received substantial increases in its appropriation from Congress, up from $289 million to $420 million between fiscal years1999 and 2001. Likewise, funding for the Substance Abuse Block Grant has risen in recent years, to more than $1.6 billion. Together, these federal block grants represent an important, and growing, source of support for public programs serving individuals with mental illnesses and addictive disorders or both. One of NAMI’s major goals for both of these programs is – through new leadership at SAMHSA – fostering integrated services for persons with co-occurring mental and addictive disorders.
Specifically, NAMI urges the Bush Administration to support legislation to create a discretionary program at SAMHSA for states seeking to waive the separate tracking and accounting requirements for mental health and substance abuse block grant dollars. In the interim, NAMI supports full funding for the new CMHS integrated treatment program to help follow through on the substantial evidence base demonstrating the superiority of integrated treatment (over parallel and sequential treatment) for persons with co-occurring mental and addictive disorders.
No Flexibility Granted to States for Integrated Treatment
In 2000, Congress enacted a new law reauthorizing all SAMHSA programs. This new law was included as part of the Children’s Health Act of 2000 (P.L. 106-310), which was signed by former President Clinton on October 17, 2000. Unfortunately, as part of the new law Congress and the Clinton Administration rejected a NAMI supported proposal to grant states flexibility when providing integrated treatment for persons with co-occurring mental illness and addictive disorders. Specifically, NAMI had proposed language that would have allowed blended block grant funding to support integrated treatment at a state’s option. In addition, NAMI also sought federal clarification that SAMHSA’s reporting requirements should not be so burdensome that states could not finance integrated treatment through the mental health and substance abuse block grants. Both modest proposals were rejected.
Instead, the new law contains a state mental health planning requirement related to persons with co-occurring disorders that will apply equally to the state substance abuse planning requirements. Specifically, Section 3407 of the new law states: "States may use funds (mental health and substance abuse block grants) to treat persons with co-occurring substance abuse and mental disorders as long as funds available under such sections are used for the purposes for which they were authorized by law and can be tracked for accounting purposes." This federal mandate to separately track each dollar is expected to result in few, if any, integrated treatment programs financed with block grant dollars. Public mental health authorities and community providers have made clear to NAMI that their agencies do not have the sophisticated management information systems (MIS) required to track increments of minutes in mental health and substance abuse services within integrated programs.
Discretionary Grant Program or Integrated Treatment Established
At the same time, P.L. 106-310 does authorize a modest federal discretionary grant program targeted to this population. Specifically, Section 3213 includes a provision authored by Senators Pete Domenici (R-NM) and Edward M. Kennedy (D-MA) establishing a discretionary grant program exclusively for integrated treatment for persons with co-occurring disorders. While this Domenici-Kennedy proposal would have originally authorized $50 million a year for such a program, P.L. 106-310 cut this "authorization level" to $40 million. (Actual funding for the program cannot occur until FY 2002 if Congress appropriates funds). The purpose of this new grant program is to provide fully integrated services rather than serial or parallel services, employ staff who are cross-trained, and provide both services at the same location. Priority would be given to persons who have a history of involvement with law enforcement or the criminal justice system; have recently been released from incarceration; have a history of unsuccessful treatment; have never followed through with outpatient services despite repeated referrals; or are homeless.
Another Study Authorized
In addition, P.L. 106-310 authorizes another study of services for persons with co-occurring disorders. Specifically, Section 3406 requires a SAMHSA study within two years of enactment that will report the manner in which individuals with co-occurring disorders are receiving treatment, a summary of improvements necessary, and a summary of evidence-based practices. NAMI has consistently argued in recent years that the existing evidence base of scientific research already strongly supports the efficacy of integrated treatment.
The U.S. Surgeon General's Report on Mental Health observes: "Substance abuse is a major co-occurring problem for adults with mental disorders. Evidence supports combined treatment, although there are substantial gaps between what research recommends and what typically is available in communities" (pages 18-19).
Further, the Surgeon General's report states: "Research amassed over the past 10 years supports a shift to treatment that combines interventions directed simultaneously to both conditions - that is, severe mental illness and substance abuse - by the same group of providers (Kosten and Ziedonis, 1997; for an example, see Mowbray et. Al. 1995), but access to such treatment remains limited. Combined treatment is effective at engaging people with both diagnoses in outpatient services, maintaining continuity and consistency of care, reducing hospitalization, and decreasing substance abuse, while at the same time improving social functioning (Miner et. al., 1997; Mueser et. al., 1997, page 288)." And lastly, the Surgeon General further observes: "Most of the treatment services for mental illness and for substance abuse are separate (and use different kinds of providers), as are virtually all of the public funds for these services. This separation causes problems for treating the substantial proportion of individuals with co-morbid mental illness and substance abuse disorders, who benefit from treating both disorders together (Drake et al, 1998)."
Background and Understanding the Issue
National studies commissioned by the federal government estimate that 10 million to 12 million Americans have co-occurring mental and addictive disorders. The prevailing research confirms that integrated treatment for co-occurring disorders is much more effective than treating these illnesses separately (see Research section below). Integrated treatment means mental illness and addictive disorders services and interventions are delivered simultaneously at the same treatment site, ideally with cross-trained staff. What is not considered integrated treatment is sequential treatment (treat one disorder first, then the other) or parallel treatment (in which two treatment providers at separate locations use separate treatment plans to treat each condition separately, but at the same time).
The addictive-disorders community argues against state discretion to combine mental-health and substance-abuse block grant funds expressly for integrated treatment because of waiting lists for other priority populations such as people with AIDS who are substance abusers and pregnant women who are substance abusers. This community further argues that integrated treatment programs can be jointly financed now so long as each and every requirement contained in both block grants, including reporting and auditing requirements, is fully met. However, the experience of service providers shows that the existing reporting and auditing requirements effectively quashes funding for integrated treatment. Integrated treatment providers argue that the requirement that every penny of the substance abuse block grant be exclusively spent on addiction services and that every penny of the mental health block grant be exclusively spent on mental health services are obstacles because such exact and strict reporting adherence does not allow financing of cross-trained staff and integrated non-clinical support services.
As an alternative to giving states discretion to combine block-grant funds expressly for integrated treatment, the addictive-disorders community advocates a new federal government discretionary and competitive grant program to demonstrate how integrated-treatment programs can work and a two-year study of the issue. The mental-illness community believes it is unrealistic to expect the federal government to establish a brand-new grant program (whose funds will likely go only to exemplary programs) and that such a program would delay resolution of the core issue: Should not both block grants financially support integrated treatment for persons with co-occurring disorders?
Research Shows Integrated Treatment Improves Recovery
"The failure of the parallel treatment system for dually diagnosed persons is reviewed followed by a description of more recently developed integrated substance abuse and mental health methods…. These studies, therefore, are consistent with the hypotheses that patients with dual disorders can be successfully rehabilitated from substance abuse disorders and that integrated treatments are superior to nonintegrated treatments." (pg. 601)
"Both professional and organizational rivalries and jealousies often conspire to add to the difficulties faced by individuals with dual disorders…. Most professionals in each field have been trained to work only with individuals having a single disorder; reformers underscore the need for cross-training of professionals in each field to improve services to patients with dual diagnosis."
"By the late 1980s it had become increasingly clear that the traditional approach of treating dually diagnosed clients through separate mental health and substance abuse service systems was inadequate…. A wide range of problems occurred with the parallel and sequential approach to treating comorbid psychiatric and substance use disorders.…"
NIDA Director Alan Leshner called integration of care a truism. "How can you ever be against it? What is needed," he said, "is research on how to deliver it. He pointed to extensive research showing parallel or sequential treatment does not work. "I would argue we have failed miserably under a fragmented system," he said.
For more information about NAMI’s activities on this issue, please call Andrew Sperling at 703-516-7222. All media representatives, please call NAMI’s communications staff at 703/516-7963.