Comorbidity of Mental and Addictive Disorders

60 Presentation COMORBIDITY OF MENTAL AND ADDICTIVE DISORDERS AUDREY MANLEY, M.D., M.P.H. Deputy Assistant Secretary for Health Assistant Surgeon General 200 Independence Avenue, S. W. Hubert H. Humphrey Building, Room 716-G Washington, DC 20201 Over the past decade, the co-occurrence and interaction of alcohol and other drug use disorders with psychiatric illness have gained increasing prominence in scientific, clinical, and health policy circles. While attention to comorbidity of mental and addictive disorders bears directly on the quality of health care available to all Americans, I would suggest that it is particularly auspicious for medically underserved populations. This suggestion reflects my confidence that research-based knowledge guides clinical practice patterns as well as the continuing refinement of our country's health care policies. It also reflects my knowledge that the poor and underserved are least likely to be afforded the full advantages of today's health care system. I would like to review key social and clinical trends as well as research activities that have heightened our awareness of the extent and implications of comorbid substance abuse and mental disorders. Against that backdrop, I will consider how this awareness can and should be harnessed to make future research, practice and service delivery patterns, and policies more responsive to problems which are associated with comorbidity and that may have a disproportionate impact on poor and underserved populations. Mental illness and substance abuse: 25 years in retrospect Health care professionals and particularly policymakers may be better able to grasp the fundamentals of mental and addictive disorder comorbidity if Journal of Health Care for the Poor and Underserved, Vol. 3, No. 1, Summer 1992 ____________________________Manley__________________________61 we understand some of the factors involved in the emergence of the problem. The past quarter-century provides a useful frame of reference for appreciating the variety of factors that have converged to exacerbate the problems of mental and addictive disorder comorbidity and to fuel contemporary interest in the phenomenon. In mental health, the mid-1960s marked the early boundary of what has come to be termed the era of deinstitutionalization and, more recently, postdeinstitutionalization . The terms denote the end effect of a number of influences that led, for better or worse, to a virtual revolution in this country's philosophy and practice of mental health care. Over a brief period, the state hospital was supplanted as a locus of long-term residential care for care for the mentally ill by a broadly diversified system of community-based care. Among the influences contributing to this radical transformation were refinements in treatment, especially the introduction of effective psychotropic medications that made outpatient care more feasible; innovative service delivery systems that were typified by a growing network of comprehensive community mental health centers; new federal programs such as Medicaid, that offered states economic incentives to reduce the inpatient rolls in state hospitals; and a healthy concern about the civil liberties of persons with mental illness. For many thousands of people with severe mental illnesses, the outcome of deinstitutionalization has been positive. With the support of families, friends, and employers, and the efforts of caseworkers and community mental health personnel, people with mental illness are in their respective communities leading productive lives that would have been unimaginable 30 years ago. Today, foresighted public laws such as the Americans With Disabilities Act of 1990 are helping to further these gains. But for a sizeable minority of patients, deinstitutionalization failed. Moving from hospital to community in the absence of even minimal follow-up, rehabilitation, or social services, many floundered, and are now found on the fringes of society, among the homeless, and in jails and prisons. In the meantime, an entire generation—the so-called young adult chronic patients— that has come of age for mental illness during the post-deinstitutionalization era may have either received limited community-based treatment or made no contact with any system of mental health care. For many of these people, easy access to mind-altering drugs and, for some, a biologically based vulnerability to drug use may help to explain the high prevalence of comorbid conditions found among them. Research suggests that regular use of street drugs among young persons with severe mental...