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Integrated treatment And The Co-occurring Disorder Patient

Integrated treatment And The Co-occurring Disorder Patient

Abstract

Individuals suffering from a substance addiction diagnosis most often are also affected with a co-occurring disorders which can include both medical and mental health symptoms in which case only make treatment more difficult and often lead to unsuccessful treatment.  Traditionally, treatment for occurring at any medical, mental health or substance abuse treatment setting is usually treated separately and there is seldom any collaboration between any of the entities involved in the care the same patient.  Numerous obstacles often arise that do not allow for any type of integrations of care for this population of patients with co-occurring disorders.
It is known by medical professionals familiar with substance abuse and mental illness that a large number of patients that suffer from a dependence problem concurrently struggle with a form of a co-occurring mental health illness as well as health issues.  The problem with treatment for this population is those with a co-occurring disorder typically have poor outcomes in regards to effective treatment.  This also coincides with lack of insight which often leads to frequent utilization of emergency departments.  Additionally, the hospitals that these patients frequent seldom communicate with the providers of these patient only adding to the cycle a “revolving door” regarding emergency department utilization.  An integrated care approach as a treatment may result in a suitable resolution to this ongoing problem.

Table of Contents

Abstract…………………………………………………………………………………….………2
Table of Contents……….………………………………………………………………………3-4
Background……….…………………………………………………………………………….5-10
General Problem Statement……….……………………………………………………………6
Specific Problem Statement……….……………………………………………………………7
Purpose Statement……….……………………………………………………………………..8
Research Questions……….……………………………………………………………………8
Hypotheses……….…………………………………………………………………………..8-9
Definition of Terms……….……………………………………………………..………….9-10
Literature Review……….………………………………………………………………..…..10-20
Overview of Literature Concept 1……….…………………………………………………10-13
Overview of Literature Concept 2……….……………………………………………..…14-17
Overview of Literature Concept 3……….………………………………………………..17-20
Method……….………………………………………………………………………………….21Research Method and Design Appropriateness……….………………………………………….21
Population……….…………………………………………………………………….………21
Sampling Frame……….…………………………………………………………………..21-22
Data Collection……….………………………………………………..……………………..23
Data Analysis……….…………………………………………………………………………24
Discussion……….……………………………………………………………………………25-29
Findings……….………………………………………………………………………………25
Limitations……….………………………………………………………………………..25-26
Use and Application of Findings……….…………………………………………………26-28
Recommendations…….………………..………………………..……………………………….29
Conclusion……….………………………………………………………………………………30
References……….…………………………………………………….……………………..31-34
Integrated Treatment And The Co-occurring Disorder Patient
Patients suffering from a substance abuse problem, more often than not, also face a battle with some form of a mental health disorder.  These patients are diagnosed has having a co-occurring disorder.  Individuals that fall under this category have historically failed in any type of treatment and are also known to have poor medical health.  These multiple diagnosis only make treatment of a patient much more difficult which often results the patient experiencing poor health, poor hygiene and a poor quality of life.  Poor habits regarding substance abuse leads to the establishment of medical conditions which only increase the chance of developing a serious disease or a worsening of an already present condition.  There has been seldom integrated coordinate between substance abuse and medical care when compared to substance abuse and mental health.  The goal of this paper is to examine if a substance abuse patient diagnosed as having a co-occurring mental illness benefit from the integrated care approach in regards to treatment and if integrated care approach could aid in high utilization and better engagement of patients
Background
A Co-occurring disorder patient is defined as a person that has a substance abuse disorder as well as a mental illness.  This disorder can be considered for a patient with a combination of any type of substance use habit as well as a mental health illness.  Some examples of this are alcoholism and depression, heroin addiction and post-traumatic stress disorder, prescription drug dependence and anxiety.  It is known by those medical professionals familiar with substance abuse and mental illness that a large number of patients that suffer from a dependence problem also concurrently struggle with a form of a co-occurring mental health illness as well as health issues.
The problem with treatment for this population is those with a co-occurring disorder typically have poor outcomes in regards to effective treatment.  This also coincides with lack of insight which often leads to frequent utilization of emergency departments.  Additionally, the hospitals that these patients frequent seldom communicate with the providers of these patient only adding to the cycle a “revolving door” regarding emergency department utilization.  Previously, the providers working in the separate treatment location – substance treatment, mental health and medical – frequently cared for co-occurring disorder patients the same way as a patient with only one disorder resulted in never meeting the unique needs of those patients with co-occurring disorders.  In-depth research revealed the necessity to address every aspect that a patient is struggling with and it identified specific targets for the optimal points in regards to the best practices to reach a treatment goal.
Additionally, an increasing mass of research proposes that integrated avenues to treatment has the potential to improve the desired outcomes of those patients with substance abuse.  Despite the fact that integrated care currently remains the ideal in the majority of clinical settings, enthusiasm regarding its approach is building and many agencies are in the transition of incorporating the integrated care standards to their practices.
Those diagnosed with any mental health disorder have a higher rate to also have a substance use issue than those without a mental health disorders.  Co-occurring disorder patients have the history of being misdiagnosed because of the due to the intricacy of symptoms, due to each differing in acerbity.  Majority of examples, patients are treated for only one disorder while the other continues to be untreated.  It is possible this is due to the fact that both illnesses can external factors such as biological, psychological, and social components.  Other justifications might be inadequate clinical training or testing, a mirroring of symptoms, or that other health issues take priority in treatment.  Regardless, the ramifications of an undiagnosed, untreated, or undertreated co-occurring disorders may result in a person of struggling with homelessness, incarceration, medical illnesses, suicide, or early death.
Patients that have co-occurring disorders are those that have the most success in regards to treatment when integrated care treatment is incorporated.  Using integrated treatment, clinicians are able to address substance use as well as mental disorders concurrently, and better managing any medical conditions better which more often results in reducing costs and developing more favorable outcomes.  Accumulating attention and growing accommodations in service networks are vital in helping target and remedy co-occurring disorders.  Early identification and treatment may improve treatment results as well as provide a better quality of life for the patients whom require these services.  This collaborative integrated approach will lead to greater outcomes and a better quality of life for patients with a co-occurring disorder.
General Problem
The problem is research has determined that those he amount of individuals suffering from a co-occurring disorder may be much higher than previously thought using DSM V standards.  Additionally, it is often seen that a co-occurring diagnosis is often associated with multiple mental health disorders.  These multiple diagnosis only make treatment of a patient much more difficult which often results the patient experiencing poor health, poor hygiene and a poor quality of life.
 
 
Specific Problem
Patients with a substance abuse problem may have an increased exposure for numerous sustained medical complications.  In regards to mental health it is not easy to identify why mental health and overall health are affiliated.  Therefore, the poor habits of substance abuse leads to the establishment of medical conditions which only increase the chance of developing a serious disease or a worsening of an already present condition.
Purpose Statement
It is known that there has been seldom integrated coordinate between substance abuse and medical care when compared to substance abuse and mental health.  Medical and substance abuse provides currently continue to function as separate entities in regards to treatment for the exact same patient.  Recent developments do shed a positive light on how integration of these services can associate with improved outcomes for these patients and allow for interventions to encourage substance abuse treatment and sobriety.
Research Questions
RQ1 Can a substance abuse patient diagnosed as having a co-occurring mental illness benefit from the integrated care approach in regards to treatment?
RQ2 How can integrated care aid in high utilization and better engagement of patients with treatment at community providers?
Hypotheses
Alternative
HO1 There is correlation between a substance abuse patient diagnosed as having a co-occurring mental health illness and suffering from untreated health problems.
Null
HO2 There is no correlation between a substance abuse patient diagnosed as having a co-occurring mental health illness and suffering from untreated health problems.
Alternative
HAO1 There is correlation between the integrated care approach and patients overall health.
Null
HAO2 There is no correlation between the integrated care approach and patients overall health.

Definition of Terms

12-step Program – model used in treatment related to substance abuse (primarily alcohol use) founded on the idea that individuals can aid one another to maintain sobriety, however it is not possible without the belief of a higher power
Alcoholics/Narcotics Anonymous- informal and unbiased group of partnership in the context to gatherings for those suffering from a substance abuse problem
Cognitive-behavioral Therapy – time-sensitive, framed, present-oriented psychotherapy focused on resolving problems and educating clients with techniques to adjust dysfunctional thoughts and behavior
Co-occurring Disorder – a person that has a substance abuse disorder as well as a mental illness.
Deinstitutionalization of Mental Health – a movement which occurred in the United States during the 1960’s which relocated mental health patients from state-run facilities “insane asylums” community mental health centers
DSM V – diagnostic and statistical manual of mental disorders
Integrated Care – collaborative approach to health care in which numerous treatment providers/agencies are involved in a patient’s treatment
Motivational Interviewing – a consoling approach which assists people resolve ambivalent thoughts and insecurities to discover the internal drive they require to change their behavior
Pharmacotherapeutic – therapeutic uses and effects of drugs in patients
Psychopharmacological Care – area of psychology and psychiatry focused on the study of drugs’ effects on behavior and mood

Literature Review

Mental health and substance abuse, the co-occurring disorder
Despite addiction treatments currently taking place, substance abuse care is still mostly occurring in segregated services, traditionally taking place in the mental healthcare setting.  Up until the deinstitutionalization of mental health cares which started in the late 1960’s during the civil rights movement, these patients with substance addiction issues were provided care from institutions or agencies specialized for the care of mental health, examples being asylums or state institutions (Yohanna, 2013).  In most cases, during that time these cases were often handled in the criminal court or state welfare systems.  Around the end of the 20th-century substance abuse treatment started to divide from the mental health treatment setting and transitioned in multiple new disciplines.  Because of this, it resulted in the development of specific programs focused on substance abuse and addictions.
During this time the substance abuse treatment standards were established and are used by these programs to rehabilitate the struggles these patients faced.  Examples of these practice standards included the 12-step facilitation therapy, the Matrix model, Motivational Interviewing and therapy, and cognitive-behavioral therapy (drugabuse.gov, 2018).  The transition of this type of treatment grew and became more influential to the point that research societies invested time to investigate the significant problem substance abuse and addiction.  This set the motion for the development of numerous institutions such as the National Institute of Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism which focused on the primary goal of addressing substance abuse and addiction.    At the time, those working in this area were open to the segregation of this type of treatment due to simplicity in the way the mental health system approached treatment for this illness.  This separation generated two separate funding sources from which the United States provided funds which only further segregated the treatment of substance abuse and addiction and the treatment of mental health.  This move, in essence, created the separation of these two services.
Sadly, the segregation of treatment additionally developed networks in which majority of treatment programs and clinicians lacked the resources, training, or experience to care for patients with co-occurring disorders and dispositions toward particular issue and general treatment theory.  As progress is made for the collaboration of mental health and substance abuse care towards a target on combined treatment for co-occurring disorders, it is possible for a moderate lack of education and training guidelines (Fisher, McCleary, Dimock, & Rohovit, 2014).  Unfortunately, this regularly brought about patients being alluded to another office/clinic for treatment of the other problem before they were qualified to be seen for their showing issue, or in overlooking the co-occurring disorders altogether.
The co-morbidity of addiction and mental health disorders is somewhat frequent in general populations worldwide (Morisano, Barbor, & Robaina, 2014).  The contrast between the mental health and substance abuse systems regarding convictions, preparing, conduct, and belief system posture critical boundaries to the viable treatment of co-occurring patients.  Mental health regularly has been contended that substance abuse issues are side effects of more deep mental trouble and that when those different issues are legitimately treated, substance abuse problems will decrease or die down.  The existence of substance abuse issues and mental health disorders are associated with adverse outcomes of treatment including a decrease in emotional functioning, increased amount of time in treatment, increased depreciation regarding care, increased inpatient stays, and an increase in medical illness from both mental health and substance abuse (Wüsthoff, Waal, & Gråwe, 2014).  This conceptualization fortifies a progression in which substance abuse issue and their treatment at times, is viewed as less real and less meriting consideration and assets.  In the meantime, the substance abuse treatment field every now and again is belief system driven, and its conflicts with the emotional wellness field on fitting finding and treatment regularly have been hostile.
Regardless of the fact that substance abuse treatment programs may fluctuate in different ways, the considerable more significant part has been affected by the Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) traditions, and the real treatment display currently utilized in the United States.  Despite the fact that these programs have contributed much to the field, they have had an unavoidable unitary impact, impervious to contending treatment models, even on account of co-occurring disorders (Sisselman-Borgia, 2018).  These programs customarily have stressed a more fierce methodology than emotional well-being programs, which have accentuated more strong systems (or have just not treated patients until the point that they are clean and sober.  Numerous substance abuse treatment providers themselves are in recuperation and alumni of AA or NA which impacted programs and stick to a theory of restraint.  These treatment programs and providers frequently dislike drugs, for example, methadone or naltrexone for their patients, though medicines are ordinary in psychological wellness programs for mental health.  This has fundamentally moderated the selection of pharmacotherapeutic mediations for co-occurring patients in numerous substance abuse treatment settings.
Mental health and substance abuse treatment likewise have contrasted in their utilization of self-improvement gatherings.  Though AOD treatment has a long custom of depending on self-improvement, especially 12-step– groups, as a necessary critical fixing, they are significantly less usually utilized as a part of the mental setting.  Integrated care which addresses mental health while treating substance abuse disorders may reduce the anxiety caused by the substance abuse symptoms leading to relapse (Wolitzky-Taylor, et al., 2018).  Despite the fact that the writing is blended on whether co-occurring disorder patients are pretty much likely than others to take part in 12-step groups prove progressively and demonstrates that when patient do take an interest, they advantage from 12-step support to such an extent or more than different patients.
In the previous two decades, self-improvement gatherings that are established in conventional 12-step programs yet have been re-organized to meet the unique requirements of individuals with co-occurring disorders have been developing in number, and assessments point to positive immediate and backhanded consequences for a few key segments of recuperation for co-occurring disorder patients.  Essentially, achieving an accord on treatment methodologies that work for co-occurring disorder patients remains a test.  Be that as it may, this might be a helpful time to try different things with new treatment approaches.  Substance abuse treatment providers who see patients with co-occurring disorders are winding up more open to attempting new techniques and solutions for substance abuse issues, as proof of the viability of these medications is amassing quickly.
Co-Occurring Disorders and Health Care
Co-occurring disorders affect the lives of patients and their families throughout all aspects of life despite age, gender, race, ethnicity, socioeconomic status, culture, or spiritual beliefs and well documented (Antai-Otong, Theis, & Patrick, 2016).  Aside from medicinally directed detoxification, mental health and substance abuse treatment clinicians continue operating independently, despite recent developments which recommend that collaboration would add to better results, and give chances to mediate patients who may profit by substance abuse.  It is estimated that nearly 45% of 20.3 million adults treated for substance use disorder further reported a co-occurring mental health disorder.  Of that sum, roughly 9.2 million Americans with co-occurring disorders, equaling 44% acquired separate treatment for mental illness or substance use, and a significantly lesser portion neatly 7% received treatment for both (samhsa.org, 2016).
For an assortment of reasons—incorporating distress with or deficient learning about substance abuse problems, lacking clinical instruments, time imperatives, the obliviousness of treatment assets, and issues of an expert ward—numerous primary care providers once in a while screen for or examine substance abuse use with their patients.  Patients with co-occurring disorders can be seen in all levels of substance abuse treatment programs (Administration, 2018).  Traditionally, substance abuse and health care have been even less incorporated than substance abuse and mental health treatment.  In addition, general, restorative specialists only treat a little extent of their patients’ substance abuse utilize problems.  Societal states of mind about addictions influence doctors and additionally the overall population due to stereotypes.  Due to their substance abuse problems, these patient are off inappropriately treated by providers who specialize in mental health and the substance abuse providers at times reject them due to the behavior in relation to their mental illness (Torre, 2015).
In like manner, numerous treatment providers are awkward about talking about substance abuse use with their patients, and few are prepared in appraisal and treatment.  The expansion of “cut-outs”— courses of action whereby wellbeing designs contract with oversaw behavioral human services organizations to give substance abuse and mental health treatment instead of repaying the facilitators—has diminished money related impetuses for providers to treat patients as opposed to alluding them.  Contrasted with patients who have one disorder, patients with co-occurring conditions frequently require more prolonged treatment, have more emergencies, and advance slightly in treatment (Today, 2018).  Because of every one of these elements, general, restorative experts are not customarily considered the proper social insurance expert to deal with treatment for substance abuse utilize issues.
Care for substance abuse addiction has been viewed as an entirely different aspect of treatment then mental health diagnosis, and treatment was often offered at separate facilities practice contrasting treatment techniques which often resulted in those suffering any mental health aliment are neglected from obtaining treatment for substance abuse (dualdiagnosis.org, Co-occurring disorders treatment, 2018).  The position of medicine regarding substance abuse treatment might change, be that as it may, due to a result of expanded enthusiasm for moving targets and brief aid for substance abuse issues into the medical setting when all is said and done, and essential care specifically. Confirmation supporting the adequacy of such medications is also developing, a few components have been distinguished that can make such integrative practices more prone to succeed (Moggi, 2015).  These components incorporate the reception of the medication and liquor issue recognizable proof and treatment start measures put forward that allow Medicare and Medicaid repayment for brief substance abuse treatment medicines in therapeutic settings.
The developing proof supporting the viability and adequacy of pharmaceuticals for substance abuse treatment additionally may urge doctors to treat such matters, in spite of the fact that reviews propose that pharmacotherapies for the treatment of substance abuse is embraced more gradually than for other therapeutic conditions (MacMillan & Sisselman-Borgia, 2018).  The degree of reception of drugs for substance abuse treatment issue additionally might be setting.  For instance, appropriation of another prescription is more probable in settings where other substance abuse treatment meds as of now are being recommended in this manner, substance abuse treatment prescriptions will more than likely be embraced in substance abuse treatment programs than in primary care setting.  Psychiatrists that are developing knowledge regarding in medicine will allow them to endeavor to further their comprehensiveness of treatment to continuously clutch a more integrated accession to medicine (Raney, 2013).
The process of referring and screening patients to these clinical setting also varies.  Indeed, mental health treatment facilitators have not routinely evaluated patients for substance abuse, and, by a similar token, substance abuse treatment providers have not methodically screened for mental health issues.  The reasons are numerous and now and again may inherently imply the absence of preparing.  The necessity for services for treatment of co-occurring symptoms require care to go above the aiding of patients to cope with their symptoms or maintain stability, but in addition to addressing the restructuring of their lives as well as increased partnership in which providers hold universal values, approaches, and a mirrored goals for patients they treat (Davidson, Arthur C. Evans, Achara-Abrahams, & White, 2014).
In any case, appraisal and the discovery of co-occurring disorders are overlooked or deferred because the supplier conceptualizes either the substance abuse or the mental health issue as the focal point and waiting to be tended to before managing some other matters.  On the other hand, a few clinicians may not feel outfitted to treat patients with complex co-occurring disorders and like to allude them out to another office for treatment. The two practices add to co-occurring disorder patients getting imperfect treatment.  Facilities need to develop creative and practical avenues to incorporate substance abuse and mental health care with treatment and additional diversions, aiming to rebuild current services in the course (Davidson, Arthur C. Evans, Achara-Abrahams, & White, 2014).
Impediments to Integrating Care for the Co-occurring Disorder Patient
Mental health, substance abuse, and medicine clinicians vary broadly in instruction and experience.  These clinicians of medicine by large are doctors or nurse prescribers and mental health providers who usually hold masters-level or higher degrees.  Clinicians that care for substance abuse occasionally use treatment practices that contrast from those providers of mental health and that these steps are cumbersome to amend with custom psychiatric procedures (Padwa, Guerrero, Braslow, & Fenwick, 2015). Conversely, the instruction and preparing for substance addiction treatment clinicians are more differed, varying from levels of education, degrees, and training.  A joint effort by mental health, substance abuse, and general health providers is particularly troublesome.  As a result of the different divisions that portray mental health and substance abuse care the more prominent detachment of mental health and substance abuse care from general health services; the partition of mental health and substance abuse care from one another; and the area of demand required by people with increasingly more acute mental health disorders, substance abuse problems in public programs separated from private-health care.
Integrated care can provide treatment to those patients that suffer from mental health issues and substance abuse problems that are co-occurring (dualdiagnosis.org, An introduction to integrated treatment, 2018).  Incorporation of techniques, running from constant attempts to enhance correspondence and facilitate care to completely integrate multidisciplinary groups have been utilized to enhance healthcare treatment. Specifics about treatment facilities can also present noteworthy boundaries to the integrated care for co-occurring disorder patients.  The framework issues are in any event as obstinate as the unending ailments themselves.  Since each of the healthcare systems are implanted in an extraordinary domain, it is additionally hard to comprehend what specific segments of a fruitful incorporated care model can be connected to different settings. When a primary care provider enables a collaborative network of treatment to occur those patients medical and mental health issues are managed collectively.  This limits the barriers patients acquire in regards to lack of trust with providers, problems obtaining referrals to resources in the community and privacy concerns when services occur in different settings (Schmit, Watson, & Fernandez, 2018).  The uniqueness of arrangement that creates in light of integrated possibilities combined with the many-sided quality of integrated care models themselves.
The presence of the co-occurrence of substance abuse and mental health as well as physical health ailments, is typical, only making it more difficult with the diagnosis and treatment of both mental and physical health (Grazier, Smiley, & Bondalapati, 2016).  Most research shows that individuals with a co-occurring disorder don’t promptly fit into either medical or substance abuse treatment clinical settings in a conventional manner.  This population has benefitted from increased services typically for more extended periods as well.  This requirement for long-haul treatment also is identified with the issue of funding for acute patients.  Integrated care possesses the ability to provide distinct treatment benefit in the plan in reduced substance abuse, mental health breaks, acute care episode, and involvement in the criminal justice system in additions to improved functioning, living stability, and a better quality-of-life (Hartzler, 2017).
All in all, some insurances, mostly Medicaid and Medicare (varying state to state) currently are outfitted to intensive treatment as opposed to long-haul care.  Consideration of repayment for extended ailment administration of co-occurring disorder care may help bring down hospitalization costs and enhance results.  Related inquiries that should be tended to are whether treatment examples and expenses vary for various co-occurring disorder and whether more rational treatment strategies could increment proper use of different treatment settings (i.e., emergency department, inpatient admissions and primary care) and diminish costs (Joseph, Kester, O’Brien, & Huang, 2017).
As a result of these advanced organization limitations, patients frequently are compelled to explore segregated frameworks of care, private and public reaching separate offices or offices affiliated with larger health systems and seeing various suppliers.  Reported barriers to providing integrated care included a lack of: reimbursement to primary care providers for delivering mental health services, reimbursement for care coordination between providers, funding for care management staff, and time to conduct mental health/substance abuse screening (nhchc.org, 2013).  Over and over again patients must facilitate their own health care, notwithstanding when appropriate linkages amongst suppliers and associations are deficient.  This can be mainly trying for patients encountering subjective and additionally useful hindrances identified with their co-occurring disorders and, as anyone might expect, many of these patients fail to complete or continue treatment.  Patients with co-occurring mental health disorders and substance abuse problems have unique treatment needs, and recent treatment evaluations are proof which recommends that incorporated treatment for these conditions might be more successful than treating each independently (Klott, 2013).
Because of the stereotypes affiliated with co-occurring disorders, innumerable patients likewise encounter impressive bias from society as well as from treatment providers, their families, as well as from themselves.  This misconception causes sentiments of disgrace and dread among individuals with co-occurring disorders (Al-Khouja & Corrigan, 2017).  Numerous individuals seclude themselves to maintain a strategic distance from humiliation or deny that they require mental health treatment.  Disgrace in our general public likewise keeps individuals in need of accepting assistance.  Social dismissal can prevent people with subjective from looking for some sort employment, keeping up stable housing and accommodating for themselves.  Under these conditions, it is troublesome for patients to accept the part of the proactive user, engaged in requesting the most remarkable quality, organized health care services.  Thus, numerous patients become lost despite a general sense of vigilance in these divided frameworks of care, and treatment start, engagement and standards for dependability in this populace are historically low.  Even after more than a decade since the implementation of the Mental Health Service Act whose goal was to advance co-occurring disorder services and appropriate funding which may be used to bring reform to the mental health care system (Padwa, Guerrero, Braslow, & Fenwick, 2015).
 
 
Method
Population
Participants in the study were sampled from several mental health outpatient clinics.  The community mental health centers were considered a specialty level of care and are located in both urban and rural settings.  The patients at the centers are typically referred by a primary care provider, emergency department or after an inpatient hospitalization for outpatient mental health treatment and follow-up.  Individuals must be able to acknowledge informed consent to partake and conclude the assessments to determine their baseline were incorporated in the survey.
The admittance criteria for the study is as follows: must be a new referral to the mental health clinic, be at least 18 years of age, have a diagnosed mental health disorder consisting of anxiety disorder, depression or personality disorder and must have a co-occurring substance abuse disorder.  The disqualifying criteria are as follows: any diagnosis of any psychotic disorder, excluding drug-induced psychosis, plans to relocate from the clinical catchment area during the extent of the study, have benzodiazepines or nicotine addiction disorder, only have a substance abuse disorder or acute medical illness.
Sampling Frame
During the development of the study, there were no known productive amounts available regarding studies examining the influence of integrated care against traditional treatment.  This study utilized a mixed method approach in regards to the data collected and analyzed.  Participants and clinicians providing the care were segregated into two groups; those participating in an integrated treatment approach and those that received care from their traditional setting, separate providers (control group).  The clinicians in both groups were instructed to provide evidence-based treatment for the mental health disorders, including the use of psychopharmacological care.  Medications were not the primary focus of the survey.
The new patients enrolled at the mental health clinics were asked to complete a diagnostic evaluation used as an anxiety screening assessment during the beginning of treatment or at their initial intake.  Those whose assessments fell within the prerequisite score set for the study were invited to participate in and eligibility assessment to determine a baseline for these individuals.  Independently licensed clinicians conducted loyalty assessments which were performed on clinicians with expertise in cognitive-behavioral therapy that would deliver the study.
The study figured from inside the set the impact estimate in light of changes from the benchmark to follow-up without a control set in a care study assessment of the impacts of thorough individual and gathering treatment.  The study was assumed to have an attrition rate of between twenty and thirty percent throughout the evaluations and treatment with a goal of having a total of one hundred and fifty active participants upon completion of the study.  Compliance for the study was determined by computing the percentage of designated components distributed in a given treatment session.
Proficiency was rated on a 0 (not at all proficient) to 6 (highly proficient) scale for each treatment session.  Participant compliance to the computer portion of the study was examined weekly and rated by clinicians for the of participants homework adherence on a scale from 0 (no homework finished) to 7 (all homework finished) and by examining the number computer sessions concluded.   Outcomes measured on the individual as well as the group.
 
Data Collection
Research staff conducted assessments via interviews which were held at the clinic.  Following randomization, patients participating in both aspects were given their personal log-in for computer access which was where the survey questionnaires were submitted.  The interactive internet based program as a reference to distribute the treatment material from clinicians. Clinician-lead sessions had correlative at home practice portions which allowed participants to submit answers to the at home assignments, observe videos, and obtain materials.  Sections of the collaborative computer program and integrated treatment approach included a cognitive-behavioral therapy base as well as elements of 12-step philosophy and historically practiced relapse prevention for substance abuse disorders.
Randomized participants in the integrated treatment program attended group assemblies as a substitute to the education group for families during one week and then continues family education groups after.  Training for therapist conducting the study included watching videos, situational role-plays, and informative sessions for computer program validating necessary skills for therapy with simulated patients.  Following training, clinicians completed a competency quiz on their ability to provided cognitive-behavioral therapy proficiency in regular role-play settings.
Therapists were allowed to instruct and distribute the integrated treatment program when they scored a minimum of 80% on the competency test quiz and when their overall role demonstration scores were graded at a minimum of adequate for at least 66% of the role plays concluded for each scenario.  Clinicians participated in supervision weekly during the study.  The training guidelines and proficiency testing elements were available if requested.  An in-depth discussion of the study and written informed consent was obtained from potential participants following interviews.
Data Analysis
The essential focus of the investigation was the connection amongst gathering and time, as this shows the diverse treatment reactions between bunches throughout the study.  One-way analysis of variance, t-tests, and x2 tests were utilized to observe the groups between discrepancies in clinical characteristics, and measures were gathered at a single point in time (Forister, 2016).  Results from the study’s data for anxiety and substance abuse conclusions used a network of multiple areas exhibit with time as a level 1 predictor and condition as a level 2 predictor of intercept and linear slope; both enabled a diverse randomly parallel participants.  These reviews included two result supervision individually to review effects on each group – during and after- as well as on an individual level to inspect the sustainment of treatment outcomes by correlating post care and follow-up monitoring.
The study encompassed all information that was collected and involved all participants who submitted at least a single assessment (included prior to treatment assessments).  No substantial correlations were discovered amongst conclusion of either post care or follow-up evaluations and appropriate pretreatment austerity protections, recommending that the expectation of a missing at random device is likely to be acceptable for this information.
To ensure no possible bias in the assessment of care effects due to missing information, the study entered sums for the result variables throughout the complete extent of the study using Statistical Package for the Social Sciences Multiple Imputation (IBM, 2018).  The study summary analyses of the entered information and noted those occurrences that the results derived of multilevel exhibits utilizing the starting data lot —which acknowledge any lapses though complete data maximum probability estimation restricted to only the least group of variables incorporated in a given analysis— variance.  Hypotheses for the study were met.
Discussion

Findings

Supporters of change have impacted suppliers and policymakers who serve patients with co-occurring disorders.  It now is by, and large recognized that these patients have needed to explore divided frameworks and that they have gotten treatment that is less open and less compelling than the medical services framework can convey.  For quite some time the presence of a co-occurring disorder diagnosis has been ignored, overlooked or misdiagnosed, health care providers and policymakers now perceive that these conditions are prevalent and that the dominant part of patients with substance abuse issues doubtlessly has a co-occurring disorder.
Research on the viability of mediations and models of nurture treating co-occurring disorders has significantly developed as of late and now is a unique focal point of the original research foundation.  Despite the fact that the difficulties of giving and considering coordinated administrations for patients with co-occurring disorders remain, health care interested parties are amassing the examination and building the authoritative models to help significant advances in furnishing all the more effortlessly open treatment with the possibility to enormously enhance results for patients with co-occurring.

Limitations

Incorporated treatment for co-occurring disorders has not been examined broadly, and the field needs to think about various intercessions and blends of interventions, ideally in controlled trial settings.  Due to the limited research, it is particularly critical to think about models of care incorporating medical, mental health and substance abuse treatment regardless of whether in medical, behavioral health or substance abuse program setting.  Most research and program improvements have concentrated on patients with co-occurring disorders extreme substance abuse issues and acute mental health illness.  It is additionally significant to inspect the impacts of incorporated treatment intercessions and models on patients with a less severe co-occurring disorder, including the individuals who may not meet symptomatic criteria for particular diagnosis yet whose co-occurring disorder issues block their odds for positive results.
Another limitation of the study used for the method is related to the ethnic foundation of the participants.  Roughly 57% of the individuals were Hispanic, followed by 37% who were White.  The remaining group of participants was 6% of African Americans and 1% of Native Americans, and the minority was Asian Americans with less than 1%.  Because of this, the results should be assumed with caution and mindfulness given to the primary population prior to one making referrals for an integrated treatment approach (Wolitzky-Taylor, et al., 2018).  Furthermore, the participants also varied on the acuteness of their illnesses which also contributed to the outcome of the study used.

Use and Application of Findings

Numerous elements have joined to concentrate and consider on the functioning and nature of care for individuals with co-occurring disorders, not slightest of which is the acknowledgment that, whatever the cause, this population have not been provided for suitably by the conventional treatment systems.  Accordingly, there is by all accounts a more prominent receptiveness to thinking about new models of tending to these patients.  Over the years many organizations have met and discussed a plan for partnered investigations into co-occurring disorders.  Different advancements, for example, the appropriation of the Healthcare Effectiveness Data and Information Set execution measures examined above and the sanctioning of national psychological well-being and dependence treatment equality enactment, most likely will affect the reconciliation of administrations for co-occurring disorders (ncqa.org, 2018).
Besides, the fast development of well-maintained integrated treatment framework will without a doubt shape the way understanding data is shared amongst patients and providers could potentially expand on a joint effort fundamentally if concerns about patient care and wellbeing are sufficiently tended to.  These ecological improvements justify close perception and concentrate as they develop.  Changes in the healthcare insurance framework and in models of administration conveyance additionally will influence the way nurture all patients, not just those with co-occurring disorders.  Backers of the health home model have advocated for incorporating behavioral health care services in a completely coordinated model for conveying primary health care, substance abuse treatment, and mental health treatment, predictable with the present health care reform that pressures less discontinuity in benefit conveyance.  A broad coalition of health care providers and partners have supported the integrated model, and it as of now is being used by many healthcare systems.  A full comprehension of this model and its qualities and restrictions is continually advancing.  However, it likely would expand coordination and nature of look after patients with co-occurring disorders.
True to the hypothesis that there is a correlation between the integrated care approach and patients overall health.  Presenting integrated care to treatment for a patient dealing with substance abuse and mental health problem was more beneficial to those only seeking substance abuse treatment in regards to reducing symptoms of their mental health and substance use.  These results allow additional evidence that substance abuse treatment alone is inappropriate for comorbid mental health disorder and substance abuse treatment.  More importantly, mental health was adequately treated during substance abuse treatment.  This discovery disputes the traditional thinking that the substance abuse issues should be addressed initially before a mental health problem can appropriately manage which usually results in untreated psychiatric illness.  In the outpatient clinical setting, integrated treatment is more effective in increasing the commitment to care regarding those patients with co-occurring disorders.
It is important to assess treatment practices and frameworks basis co-occurring care competency. Analysts and policymakers have contended that more extensive accepted procedures should be created that apply to the whole arrangement of care and that require incorporated framework arranging including both mental health and substance abuse treatment organizations, and that attention is supplanting an emphasis on best practices at the program level on the framework level.  This frameworks level research ought to incorporate investigations of the advancement, refinement, and spread of measures of hierarchical co-occurring disorder limit.
People with moderate to acute mental health illnesses are objected to numerous barriers to accessing health care. These obstacles are complex and range from the impact of the individual’s socio-economic status, the ability arrange for transportation to appointments, and to the path that primary health care is currently delivered.  Because this population is in strong demand for primary health care, it has almost certainly gone unmet, leading extremely high numbers of visits to emergency departments and increased burden on the Medicaid and Medicare systems.  Those individuals’ that have issues with mental health and have acute medical conditions are frequently overlooked.  Diagnostic coinciding can hide psychiatric ailments.  Lastly, mental health symptoms share similar characteristics with physical symptoms which can hinder preventative identification of the co-existing conditions.  Due to this, there is a correlation between a substance abuse patient diagnosed as having a co-occurring mental health illness and suffering from untreated health problems.
 
Recommendation
A patient diagnosed with a co-occurring disorder involves a significantly more extensive combination of treatment and may be underserved in the same programs where patients with more severe conditions get priority clinical or program consideration.  Consequently, policymakers and program organizers trying to enhance therapeutic services frameworks for co-occurring disorder patients must take care to not “coordinate” projects to the degree that non-co-occurring disorder patients, particularly those with substance abuse issues, successfully are barred from treatment since they don’t meet indicative criteria.  Models of administrations conveyance which has been supported by the National Association of State Alcohol and Drug Abuse Directors, ought to be considered and fused.  These models, which underscores a continuum of the dependence of chemical reliance and mental health services given the consolidated seriousness of co-occurring disorder, mental health, and substance abuse issues, unequivocally incorporates less acute patients whose treatment may occur in any of the three treatment settings.
Additionally, recent studies only targeted a small portion of this demographic.  Further research and more studies should be conducted in regards to acuteness, specific demographics (age, sex, ethnicity and socio-economic status) and insured patients versus non-insured patients.  By achieving this, it would allow for a more efficient avenue to better define and observe integrated treatment to traditional parallel treatment.  These results would reveal that whether or not posttreatment outcomes improved, worsened or remained the same.
 
 
Conclusion
Providing an integrated care approach in treatment aids patients and their providers. It mixes the knowledge of behavioral health, substance abuse, and primary care providers, with feedback from patients and others involved in their care.  This makes a collaborative based approach where behavioral health care and primary care are offered in a similar setting.  Shared treatment of these patients’ mental and physical ailments is important to enhance results under the two systems and prevent monetary waste of those non-compliant patients to maintain a strategic distance from pointless expenses of rebelliousness among patients who experience acute physical problems and increased treatment success and engagement.

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