Kenneth Minkoff

Dual Diagnosis Capability: Moving from Concept to Implementation

What is dual diagnosis capability (DDC)? As mental health and substance abuse treatment programs are increasingly recognizing that they are serving more complex populations, commonly with co-occurring disorders, they face the following question: Within the context of scarce resources, how do they provide services in a manner that is consistent with their existing mission and program design, but that also recognizes, accommodates, and incorporates attention to the increasingly complex needs of their service population? The answer to this question is embodied in the concept of dual diagnosis capability (DDC), and while this concept is by no means universally understood, the meaning of DDC is becoming clearer through the work of hundreds of agencies and programs throughout the United States and Canada involved in the DDC development process. The evolving concept of dual diagnosis capability refers to the notion that every agency/program providing behavioral health services must

Development of Service Intensity Criteria and Program Categories for Individuals with Co-Occurring Disorders

SUMMARY Many patients present a clinical situation in which psychiatric symptomatology and substance related symptomatology are inextricably intertwined. A paradox exists for these patients, in that both the addictions and mental health systems of care, and the level of care assessment methodologies associated with each system, are designed for one type of disorder only, or only one disorder at a time. As a result, these individuals are perceived as “system misfits.” Our inability to assess these patients accurately and place them appropriately contributes to poor outcomes and high costs. These costs consist of expensive utilization of scarce system resources. There is a growing need for a more integrated methodology for level of care assessment, in which both psychiatric and substance symptomatology can be assessed simultaneously to generate a wider array of programmatic interventions for individuals with co-occurring disorders. This article describes efforts to build upon the Patient Placement Criteria published by the American Society of Addiction Medicine, Second Edition (ASAM PPC-2) to develop a revised instrument that is much more capable of evaluating the placement needs of individuals who present with combinations of psychiatric and substance symptomatology.

Developing Welcoming Systems for Individuals with Co-Occurring Disorders: The Role of the Comprehensive Continuous Integrated System of Care Model

Abstract This paper reviews a best practice model for design and implementation of system-wide integrated services for individuals with co-occurring disorders, and illustrates the application of that model to the implementation of the specific clinical attitude and practice of welcoming in a number of ongoing Comprehensive Continuous Integrated System of Care (CCISC) projects. Welcoming, while not formally an “evidence based best practice,” is a clinical service delivery standard that also creates a strategic energy to promote implementation of other best practice interventions. Given that CCISC can be designed within the resource base of any system, and given that initial projects have been able to describe some early success in creating meaningful shifts in clinical practice, the model appears to have some face value in application to complex systems. Clearly, more formal evaluation of system, program, and client outcomes from CCISC projects is needed; the authors are currently in the process of designing such evaluation studies.

Parasuicide and the menstrual cycle

Abstract A study of 74 patients admitted to the Regional Poisoning Treatment Centre at the Royal Infirmary, Edinburgh, failed to reject the null hypothesis that parasuicide occurs at random in relation to the menstrual cycle.

What Is Integration? Part II

The previous edition of this column began to address the concept of “integration” as applied to mental health and substance abuse, and attempted to develop a broad conceptualization of the definition of integration, and then to apply that conceptualization to an understanding of “systems integration” and “services integration” at the system level. The goal of this edition of the column is to adapt that same conceptualization to an understanding of integration at the level of program design and at the level of clinical interventions provided to individuals and families with behavioral health needs: in short, to discuss “integrated programs” and “integrated interventions.” The definition of integration in the previous column was stated as follows.

Innovations in Integrated Dual Diagnosis Treatment in Public Managed Care: The Choate Dual Diagnosis Case Rate Program

This article describes the implementation and preliminary evaluation of a dual diagnosis case rate program developed as a collaborative experiment between a public managed Medicaid organization (MHMA) and a specialized integrated dual diagnosis provider (Choate) with a vertically integrated, managed-care oriented system of care. The case rate program applied to dually-diagnosed inpatient referrals for a period of 65 days. On admission, 68% of the patients had little insight, motivation and compliance regarding addiction or psychiatric management. Nonetheless, 56% maintained sobriety for 65 days, and 49% of these were still sober at 95-day follow up.

Dual Diagnosis Enhanced Programs

In 2001, the American Society of Addiction Medicine Patient Placement Criteria, Second Edition, Revised (ASAM PPC-2R) (American Society of Addiction Medicine, 2001) introduced the concepts of dual diagnosis capability (DDC) and dual diagnosis enhanced (DDE) addiction programs into the national lexicon. The original definitions of DDC and DDE addiction programs were relatively brief. DDC programs “address co-occurring . . . disorders in their policies and procedures, assessment, treatment planning, program content, and discharge planning” (American Society of Addiction Medicine, 2001, p. 362; Center for Substance Abuse Treatment, 2005, p. 33) so that program staff are able to address co-occurring disorders routinely in relapse skills, recovery environment, and readiness to change “through individual and group program content.” DDE programs are able to provide primary substance abuse treatment to clients who are, as compared to those routinely treated in DDC programs, “more symptomatic and/or functionally impaired as a result of their cooccurring mental disorder” (American Society of Addiction Medicine, 2001, p. 10, Center for Substance Abuse Treatment, p. 33). Nonetheless, the fundamental message was very important: co-occurring disorder is an expectation in addiction treatment settings, and a continuum of addiction programs needs to incorporate routine DDC into its full array of services and plan for some DDE service components in order to provide access to episodes of addiction treatment for individuals who would be unable to receive treatment routinely in DDC programs. Further, fewer and

Rebranding “Community Mental Health”

What do we mean by ‘‘Community Mental Health’’; what does it mean to be a ‘‘Community Psychiatrist’’? One assumes these are easy questions to answer, but the responses are not as simple as they may seem. Let’s start with some simple history: Community mental health as a term originated over 50 years ago. Related to the work of seminal pioneers like Erich Lindemann, the term originally referred to addressing the mental health needs of an entire community, rather than just individual patients, and to engaging in community consultation that would leverage natural caregivers to respond to crises and promote community health. This concept was transformed by the Community Mental Health Center Act (1963), which led to the first wave of federally funded community mental health centers in the mid to late sixties and early seventies. Although many of these centers initially aspired to broad community missions, their development was heavily influenced by the de-institutionalization movement of the same time period, and the concept of community mental health evolved to include and focus on service in the community (as opposed to in the hospital or in the institution) for adults with chronic and severe mental illness and children with severe emotional served in the public sector. Finally, because the generativity of community mental health arose from several broad social movements (community focus and community organizing; publicly funded and organized mental health service delivery in catchment areas across the nation; the de-institutionalization and ‘‘liberation’’ of individuals who had been trapped in institutions for decades), community mental health and community psychiatry have long been associated with a ‘‘cutting edge’’ movement in response to the challenge of providing innovative services for those most in need and least able to pay. So what is community mental health; what does it mean to be a community psychiatrist? And perhaps the key issue: does this all mean the same thing now as it did 50 years ago? Some questions might help us determine a response:

Strategic implementation of systems change for individuals with mental health and substance use disorders

Abstract The parallels or similarities between the federal approach to systems change to support services integration, and between the Comprehensive Continuous Integrated System of Care implementation process at the state or county and regional level, imply that there may be common strategic elements in the process of achieving system transformation to support widespread availability of integrated services in any system for any population. These approaches both involve fairly complex mechanisms of promoting change, built on established data-driven methodologies, such as continuous quality improvement, which have not been well-studied in large behavioral health systems attempting to implement technology transfer. This article discusses those strategies and the parallels between them. Recognition of these mechanisms may facilitate better alignment between federal and state or regional activity, provide a template for other systems seeking to create their own design process to improve services integration and, finally, suggest opportunities for design of large-scale systems research on the implementation and outcomes of integrated services development.

Inspiring a Welcoming, Hopeful Culture

Community psychiatry has unique values and a unique vision, which radically sets it apart from other behavioral health “disciplines.” Community psychiatry provides a safety net service for a “community”—for a defined population that may need help with behavioral health issues of all kinds. This is critically important: as a safety net provider, anyone who is not “caught” in your net will not receive services anywhere. The consequences of not being engaged may be dire, and in fact, may be a matter of life and death. Consequently, the pride of community psychiatry is its capacity to be responsive to the needs of people and families—“customers”—who have serious needs and would not be able to receive services anywhere else. This responsibility extends not just to the “easy” customers, the ones who neatly fit into our existing service packages, but particularly to “complicated” customers, the ones who may not fit at all, and yet are desperate for help and hope.