Researchers are already busy trying to determine what treatments work best. But conducting research on co-occurring conditions requires investigators to ask new questions and develop new ways of working, noted Constance Weisner, Dr.P.H., M.S.W., a professor of psychiatry at the University of California and an investigator in the Division of Research at Northern California Kaiser Permanente.

"We need to move away from the traditional paradigm of investigators setting the research agenda alone and move toward developing questions in collaboration with clinicians," she said, noting that health plan administrators, primary care providers, accrediting bodies, policymakers, and others should be involved. She described a cyclical process: a continuous loop of brainstorming questions, studying interventions,

implementing findings, and using the results to identify new questions.

Researchers also need to put more emphasis on studying the elements that influence adoption of best practices, said Dr. Weisner. Although a lot of research shows that integrated treatment is effective, for instance, most clinical trials focus on homogeneous populations, which may not represent the demographics of a particular treatment center or service provider accurately. Incentives for Quality

Financing is one of the real-life factors that affect the treatment of co-occurring disorders.

Noting that people with alcohol dependence are more likely to have mood disorders, personality disorders, and other drug problems, NIAAA Director Ting-Kai Li, M.D., explained that problem drinkers may be medicating themselves to relieve stress and other conditions.

"Over the last 5 years, national attention on the financing of services for co-occurring conditions has been growing," said Mady Chalk, Ph.D., Director of the Division of Services Improvement at SAMHSA's Center for Substance Abuse Treatment (CSAT). The Institute of Medicine's 2001 report on gaps in health care quality led to an increased focus on measuring quality and developing financial incentives, Dr. Chalk said. The Institute is now drafting a report specifically on substance abuse and mental health.

Constance Horgan, Sc.D., Director of the Schneider Center for Behavioral Health at Brandeis University, called for a

clear and direct link between quality and financing of services for individuals with co-occurring conditions.

As an example, Dr. Horgan described the work of the Washington Circle, a group of researchers, substance abuse treatment providers, health care policy experts, and others convened by CSAT in 1998. The group developed a framework for performance measures across the continuum of care based in four core domains-prevention/education, recognition, treatment, and maintenance of treatment effects. To drive quality improvement in substance abuse treatment, the group has initially developed and tested measures that focus on the front end of treatment: identification, initiation, and engagement.

The National Committee for Quality Assurance, the U.S. Department of Veterans Affairs, and many public systems have adopted these measures or are considering doing so. In one study of individuals who get health insurance through large employers, the group found that private sector health plans needed to improve significantly on ways to identify substance abusers, and to initiate and sustain treatment.

Health Disparities

Another area that needs improvement is access to treatment of co-occurring conditions for members of all racial and ethnic backgrounds, the conference's last plenary session emphasized.

For example, HIV/AIDS is a condition that often goes hand in hand with substance abuse. The epidemic disproportionately affects African Americans, said NIDA Director Nora D. Volkow, M.D.

She noted that African Americans represent half of all HIV/AIDS cases and that African American women represent about 70 to 75 percent of all infected women. Injection drug use accounts for 30 percent of cases, she explained. Drugs and alcohol play

SAMHSA's Report to Congress

The full text of SAMHSA's 2002 Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders is available on the SAMHSA Web site. Chapters include information on characteristics and needs of individuals with co-occurring disorders, evidence-based practices, barriers to treatment, Federal block grants and state program activities, and the Agency's 5-year blueprint for action. Visit www.samhsa. gov/reports/congress 2002/index.html.

Developing Treatment Programs

SAMHSA'S Strategies for Developing Treatment Programs for People with

a role in heterosexual transmission of the disease because many individuals are under the influence when transmission occurs.

Pervasive ethnic and racial disparities in substance abuse and mental health treatment are the norm, reported Margarita Alegria, Ph.D., a professor at Harvard Medical School and Director of the Cambridge Health Alliance's Center for Multicultural Mental Health Research. The underlying reasons for these disparities in services are not fully

NIDA Director Nora D. Volkow, M.D., speaks about the importance of ensuring that children and adolescents are one of the primary focuses of prevention research because they are at the greatest risk when it comes to substance abuse. An important

component of this research is studying developmental changes-particularly in the brain-that may make adolescents more

Co-Occurring Substance Abuse and Mental Disorders provides information on methodology and key lessons on designing services for adults with co-occurring disorders. This resource also includes appendices with information from expert panels and telephone surveys, as well as training curricula.

Both publications are available from SAMHSA'S National Clearinghouse for Alcohol and Drug Information at P.O. Box 2345, Rockville, MD 20847-2345. Telephone: 1 (800) 729-6686 (English and Spanish) or 1 (800) 487-4889 (TDD). Online, the publications are available at www.oas.samhsa.gov.

understood, Dr. Alegria said. She emphasized that understanding these factors is critical because of the rapid growth of ethnic and racial minority populations across the Nation. For more information on co-occurring disorders, visit SAMHSA'S Web site at www.samhsa.gov. More details about the conference are available at www.cccconference.com.▸

-By Rebecca A. Clay

Editor's Note: Twenty panels convened over 3 days at the Complexities of Co-Occurring Conditions Conference held in Washington, DC, June 23 to 25. Two panels are described here. Additional panel coverage and photos are available online at www.samhsa.gov/SAMHSA_News.

A farm scene was probably the last thing conference participants expected to see at a session on "Improving Outcomes Through Organizational and Policy Change."

But to Harold Alan Pincus, M.D., a professor and Executive Vice Chair of the Psychiatry Department at the University of Pittsburgh School of Medicine, the image's depiction of silos perfectly illustrated the lack of integration between mental health and substance abuse systems. "Silo-ization" is one of the biggest barriers to integrating services for co-occurring disorders, said Dr. Pincus, who is also a senior scientist at the RAND Corporation and Director of the RAND-University of Pittsburgh Health Institute.

Administrative obstacles include separate funding streams, different licensing and credentialing requirements, and an overall scarcity of resources that leads to increased competition. Clinical obstacles include the dearth of empirical data, confusion about appropriate roles, and the fact that one condition can exacerbate the symptoms of another and prevent successful engagement in treatment.

Important philosophical differences also exist between the two communities. Substance abuse treatment providers are often reluctant to allow psychotherapeutic medications for individuals with mental illness. On the other hand, mental health treatment providers often require individuals to be both alcohol- and drug-free as a condition for entry into treatment.

But there is hope, said Dr. Pincus, citing SAMHSA's Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders, the Agency's State Incentive Grants for Treatment of Persons with Co-Occurring Substance Related and Mental Disorders, and the creation of a Co-Occurring Center for Excellence (see page 16).

Audrey Burnam, Ph.D., of RAND then described how state mental health, substance abuse, and Medicaid authorities are tackling the problem of co-occurring disorders.

Summarizing the results of a 23-state study, she said that all made broad efforts to build consensus and cross-train workforces. Some states already had changed regulations or policies to facilitate integration, such as adapting reimbursement rules, modifying licensing requirements, and setting standards for provider competence.

Katherine E. Watkins, M.D., M.S.H.S., a natural scientist in the health program at RAND, summarized a literature review of evidence-based practices for those with substance use disorders and affective or anxiety disorders.

Surveying documents produced between 1990 and 2002, the researchers noticed two broad shifts in thinking. While earlier publications urged providers to treat substance

Harold Alan Pincus, M.D., of the University of Pittsburgh School of Medicine and RAND, compared the lack of integration among the mental health, substance abuse, and other systems to separate silos on a farm.

abuse before tackling any mental health problems, current guidelines emphasize the importance of simultaneous treatment. In addition, guidelines now view psychiatric medications as an important part of treatment for those with co-occurring conditions.

Robert Drake, M.D., Ph.D., Vice Chair for research in the psychiatry department at Dartmouth Medical School, then reviewed the data for people with more severe mental illness and less severe substance abuse, a category of co-occurring conditions that has been more extensively studied than others. There is plenty of evidence-29 controlled studies so far-to show that integrated treatment does work, according to Dr. Drake.

Although it's still not clear which specific interventions work best, researchers have identified several key components of integrated treatment:

Persons should receive individualized treatment from a clinician or team able to address both mental health and substance abuse disorders.

Treatment should proceed in stages. Providers should first engage individuals in treatment, provide therapy designed to motivate them to change, and only then provide active treatment.

Treatment providers should also address other problems individuals face, such as housing, jobs, and family issues.▸

--By Rebecca A. Clay