There are currently no provincial directions on delivering services to people with concurrent disorders, despite the fact that Ontario has focused much attention on integrating the mental health and addictions system. The prevalence and impact of concurrent disorders varies largely by not only substance of use (e.g. alcohol vs. illicit drugs), but also by specific mental health diagnosis. It was identified that 37% of those diagnosed with an alcohol disorder are also likely to have a co-occurring mental health disorder during their lifetime; whereas the likelihood of co-occurrence for those abusing substances beyond alcohol is estimated to be 53% (Concurrent Disorders Policy Framework, 2005). It is important to note the variation of co-occurring disorders by medical diagnosis as well. Skinner et al. (2004) identified:
- Among people who have had an anxiety disorder in their lifetime, 24% will have a substance use disorder in their lifetime.
- Among people who have had major depression in their lifetime, 27% will have a substance use disorder in their lifetime.
- Among people who have had schizophrenia in their lifetime, 47% will have a substance use disorder in their lifetime.
- Among people who have had bipolar disorder in their lifetime, 56% will have a substance use disorder in their lifetime.
Antisocial and behavioural issues are associated with having a concurrent disorder; as are legal and/or justice involvement (Rush et al., 2008). Data from North America suggest that 10-20% of people experiencing homelessness have co-occurring mental health and substance use disorders, although some believe that the actual prevalence is much greater (O’Campo et al., 2009).
Rush et al. (2008) states that “People with co-occurring disorders are more likely to seek care, accounting in large part for the higher prevalence of co-occurring disorders in mental health, substance use, and more generic health care services. This higher utilization translates into higher health care as well as costs in many other sectors (e.g., welfare). That said, a very significant percentage of people with co-occurring disorders do not seek any help at all and those that are engaged with community services are more likely to report inadequate and unsatisfactory treatment and support.”
Systemic, administrative and attitudinal barriers often confront people with concurrent disorders who do seek services and supports. In both the mental health and addictions sectors treatment outcome studies have consistently reported the negative impact of concurrent disorders on treatment retention and effectiveness (Rush et al., 2008).
Concurrent disorders impact individuals, families and society, as well as the health and social services system. The Canadian Mental Health Association, Ontario and Addictions & Mental Health Ontario have prepared this agenda-setting report to identify priority issues in planning, delivering and monitoring services for people with concurrent disorders that require attention in Ontario to ensure a high-quality health system, responsive to clients and accountable to funders.
The goal of this project was to conduct a scan to profile system issues that should be addressed in Ontario to set in motion the impetus for enhancing services to people with concurrent disorders.
An Advisory Committee was convened that engaged select front line service providers in the mental health and addictions sector to inform this scan (Appendix I). Specifically:
- A policy focused review was conducted of reports and recommendations prepared over the past 15 years by non-governmental organizations, advisory bodies to government, and provincial and national directions in mental health and addictions that address the delivery of services for people with concurrent disorders (Appendix II).
- Key informant interviews were conducted. Key informants were suggested by the project advisory committee. Selection criteria included knowledge of current and historical issues related to concurrent disorders from a policy, system planning and provincial perspective. A key informant finding report was also prepared (Appendix III).
- Key themes from the policy review and key informant interviews were synthesized to identify key issues requiring further attention. A survey was then prepared and sent to 270 mental health and addictions agencies in Ontario to validate and expand on priority issues identified thus far. Survey findings were analyzed and a report on the findings was developed (Appendix IV).
- Lastly, existing concurrent disorders data sources available in Ontario were identified and key issues summarized (Appendix V).
1. Definition of Concurrent Disorders
There is currently no consensus regarding what conditions should be included under “concurrent disorders.” Concurrent disorders are variously defined by diverse health service providers and sectors. A lack of common definition has implications for scoping policy directions, eligibility for services, responsiveness to client needs, collaboration and identifying core competencies for staff.
A common definition of concurrent disorders was identified as an issue that requires further attention. Variances in current definitions include whether behavioural addictions such as gambling, shopping and sex are included. Another significant factor is whether tobacco dependence is included in the definition.
2. Lack of Directions
There is currently lack of provincial direction to address services for people with concurrent disorders. This is particularly disconcerting given recent attention on mental health and addictions policy and the release of a new 10-year mental health and addictions strategy for Ontario. There have also been no recent provincial investments made towards concurrent disorders service delivery.
Provincial leadership through the Concurrent Disorders Ontario Network (CDON) supported by the Centre for Addiction and Mental Health (CAMH) was active from 2005 to 2010. There is no official information on why CDON is no longer in existence however key informants did recall that the funding and resources for CDON were not maintained by CAMH to resource CDON. No other network or group has taken over the provincial leadership role or even components of CDON’s work.
Lack of directions in Ontario has resulted in inconsistencies across the province on when, what and how concurrent disorders services are provided. With no provincial mechanism in place to give direction to delivering services for people with concurrent disorders, there is consequently no monitoring of existing programs. The Multi-Sector Service Accountability Agreements (M-SAAs) lack indicators that have the potential to monitor need and coordinate services for people with concurrent disorders within LHINs. This situation needs to be remedied under Ontario’s Action Plan for Health Care, with the ultimate goal of providing the right care at the right time in the right place.
As there are no provincial directions, there has been variable Local Health Integration Network (LHIN) planning for concurrent disorder services. Some LHINs include services for concurrent disorders within their Integrated Health Service Plans (IHSPs) while others do not. These inequities are reflective of differing levels of satisfaction expressed by health service providers with their LHIN’s planning for concurrent disorders. Inequitable local capacity restricts access to services and supports that are key to addressing the needs of clients with concurrent disorders.
Eligibility requirements further compound access issues. In general, addiction agencies will more often accept clients with mental health services while mental health services are less likely to accept clients with addiction issues.
However, key informants identified that there is much good work happening at the local level by health service providers with respect to concurrent disorders. Local stakeholders, for example, are setting up local inter-agency committees to address the needs of people with concurrent disorders. There are new practices emerging. Cross training within addiction and mental health services has also been deemed successful. As previously mentioned, this is often occurring without provincial direction and sometimes without LHIN guidance.
3. System and Service Coordination
System navigation is a challenge for many people with concurrent disorders. Further attention to accessing and transitioning through the continuum of care for people with concurrent disorders is required. These problems are compounded for clients with more complex needs, such as people who have a dual diagnosis and a concurrent disorder; or those in conflict with the law.
System and service coordination also requires attention in emergency departments. Addressing emergency department visits by people with concurrent disorders is required. Key informants identified that people with concurrent disorders use emergency departments because adequate community supports are not in place and as a result emergency departments deal with the overflow.
System and service coordination is an issue that requires attention for people with concurrent disorders who use multiple services, simultaneously or episodically. The connection between services, lack of capacity to meet needs, sharing information between services and shared care for this population is a challenge.
Integration has been identified as a priority across Ontario, although how integration is defined varies from region to region. As of yet, there is lack of clarity by funders, health sectors and some health service providers in the province regarding how service coordination/integration can support increased responsiveness to people with concurrent disorders (although models have been proposed, including by CDON). In addition, it is not yet clear how the current focus in some LHINs on organizational integration through amalgamations and mergers would inform the planning and delivery of concurrent disorders services. The impact of integration on concurrent disorders services does not seem to be a point of discussion or planning.
Inter-sectoral integration between the mental health and addictions sector and other sectors to address individuals with concurrent disorders was also identified as an important issue, particularly within the justice system.
5. Inter-sectoral Differences
Organizational culture, funding requirements, and accountability mechanisms as well as service differences and territoriality are issues that require further attention for planning and delivering services to people with concurrent disorders, according to key informants. These issues have been identified as a challenge to cooperation amongst the mental health and addictions sector. Differences in backgrounds, training and approaches must be recognized and overcome in order to support collaboration of mental health and addiction service providers to address the needs of individuals with concurrent disorders.
Federal and provincial reports on mental health and addictions have discussed the need for appropriate and adequate funding in order to provide concurrent disorders services. However, funding is a challenge for concurrent disorders services as there have been a lack of investments, given no provincial directions or planning. Many agencies are providing concurrent disorder services without dedicated funding. They are not receiving funding from either their LHIN or other sources. Agencies reported that 25% of the services that they provide for concurrent disorders are not funded.
7. Data Collection
Data is a key source of information to plan and monitor services for people with concurrent disorders. There are significant differences in how the community mental health sector and the addictions sector collect data on concurrent disorders services. Existing data sources cannot be linked. Currently, there is no central repository to compile all concurrent disorders service data on which to inform future rounds of health system decision-making.
Developing program standards for concurrent disorders were identified as a priority by health service providers. Program standards were also identified as being an important bridge across the mental health and addictions sector.
9. Evidence-based Practice
Health service providers support the need for more evidence-based services. Existing evidence has been identified however there needs to be more of a focus on providing services to people with concurrent disorders. There has been some movement within the mental health sector for increased evaluation of programs however this requires more attention in the addictions sector.
Service providers are seeking professional development on core competencies to deliver programs to people with concurrent disorders. Access to training was identified in our survey as the top priority for enhancing service delivery to people with concurrent disorders.
Availability of clinical supervision to health service providers was deemed inadequate, and this was identified as being both a human resource and professional development issue. Lack of standardization in training and the lack of definition of core competencies have led to human resource challenges, as there are variations amongst staff’s knowledge in concurrent disorders.
It was also highlighted that attention should be given to distinguishing between concurrent disorder-capable and concurrent disorder-enhanced. Concurrent disorder-capable are skills that all health service providers in the field should have. They should be “capable” of screening for mental health and addiction conditions, collecting data and developing treatment plans. Concurrent disorder-enhanced means staff have more in-depth expertise in providing concurrent disorders interventions.
11. Human Resources
Agencies are experiencing human resource shortages that impact the delivery of concurrent disorder services. This is attributed to lack of funding to hire dedicated concurrent disorders staff, difficulty in recruiting staff at a competitive wage, as well as lack of staff that is trained to work with this clientele.
12. Special Populations
Three priority populations were identified by our key informants and health service providers as requiring special attention when planning the delivery of concurrent disorders services. These three populations are:
- Aboriginal Peoples
While the needs of youth with concurrent disorders were identified as a priority, of particular urgency is to address the needs of transitional-aged youth. Concurrent disorder issues frequently emerge in adolescence and early adult years. A key concern is that when youth transition into the adult system, the adult system is not adequately responsive to meet age-specific needs. This population is a high user of the health system and can present with complex needs.
Seniors are another population that require priority attention when planning concurrent disorders services. There is very little attention being given to seniors with concurrent disorders.
Aboriginal peoples require priority attention when planning concurrent disorders services. The prevalence rates of mental health issues, co-morbidity and suicide amongst this population is a major concern. Aboriginal peoples experience increased levels of stigma, and require culturally competent care.
The Canadian Mental Health Association, Ontario and Addictions & Mental Health Ontario have prepared this agenda-setting report to identify priority issues in planning, delivering and monitoring services for people with concurrent disorders that require attention in Ontario.
Ontario’s Comprehensive Mental Health and Addictions Strategy includes the goal “to provide timely, high quality, integrated, person-directed health and other human services.” Key methods to achieve this goal include strengthening and integrating mental health and addictions services and enhancing the capacity of the health system to provide integrated services.
Ontario is currently setting priorities for year 4 and beyond of the strategy. Our next step will be to raise awareness of community mental health and addictions service issues in order to set in motion actions to support implementation of the strategy.
Our associations are ready to meet with policymakers and decision-makers and engage the community mental health and addictions sector, as well as other advisors, to improve the planning, delivery and monitoring of high-quality services for individuals with concurrent disorders in Ontario.
That the Ministry of Health and Long-Term Care and Local Health Integration Network (LHIN) representatives work collectively with the Canadian Mental Health Association, Ontario and Addictions and Mental Health Ontario to remedy issues in community-based services for individuals with concurrent disorders that have been identified in this report.