Comorbidity treatment service model evaluation

Service structure

Page last updated: August 2009

This sub-domain includes findings about:

Service sectors

Fifteen treatment services belong to the non-government or private-not-for profit sector, while two are government organisations. Of the 17 services, none described their service or program as a mental health (MH) service. Eleven were described as alcohol or other drug (AOD) services, three as combined MH and AOD services, and three described their service as 'other'. The latter includes the following descriptions:
  • Ethnic community centre that provides various social welfare services
  • Capacity building services to regional Clinical Mental Health, Psychiatric Disability Support and AOD services
  • Youth health with focus on AOD, mental health, and sexual health.
Further, one of the AOD services noted that 'the project is encouraging the development toward comorbidity'.

Of the 17 services, two are Indigenous services, and one service has a large proportion of Indigenous clients. Five services cater only for adolescents/young people, and nine services provide a residential program.

Service size and type

Taking into account the number of employed clinicians and other professional staff, services were categorised into small (n=2-20), medium (n=27-80), and large (n=124-403) services. The smallest service has two clinical staff, while the largest employs 403 clinical/professional staff (the latter has a total of 423 staff and volunteers). The majority of surveyed services are small. Three services are medium-sized and two are large (see Table 5 below).

Table 5 also distinguishes between AOD services and services that were described either as combined AOD and MH services or 'other'. For the purposes of this report, the latter will be referred to as combined services.

Table 5: Service size by type of service

Service typeSmallMediumLargeTotal
AOD
8
2
1
11
Combined
4
1
1
6
Total
12
3
2
17
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Types of treatment provided

The 11 AOD services provide the types of treatment as described in Table 6. Treatment types include withdrawal management/detoxification, rehabilitation, pharmacotherapy, counselling, support, information provision, assessment, and other treatment types.

Other types of treatment provided included (number in brackets if noted more than once):
  • Case management (2)
  • Group work
  • Community education to schools and other community agencies
  • Community development
  • Assertive outreach
  • Family support
  • Day programs
  • Supported accommodation
  • Referral
  • Secondary consultation
  • Clinical psychology.
The three combined AOD and MH services described their treatment types as follows:

Public Mental Health Services–adult case management, integrated model (crisis, mobile, outpatient, bed based managed in an integrated manner) Public D&A service–state-funded service: counselling, case management, housing, NSP, outreach, pharmacotherapy, nursing (general health and withdrawal) Managed jointly but operating separately. (Large service)

Those who have co-existing mental health and drug misuse. They are primarily between the ages of 19 and 29. We have several outpatient treatment programs for those aged 12–25 and have a residential facility operating as a Therapeutic Community. We have six halfway houses that operate on a step up, step down system, depending on the presenting difficulties of the client and their ability to cope. We have a medical team, consisting of a credentialed mental health nurse–working full time, nurses assistant, consultant GP three days per week, two consultant psychiatrists who do one session per week each, MOU with local integrated mental services, two dual diagnosis clinicians (psychologists) who work from different pots of funding, two contracted psychologists contracted through the Medicare better access initiative, DoHA contract for improved services that provides one clinician to co-ordinate improved services for comorbidity inpatient and outpatient services that we offer across the organisation, MOUs with the universities to assist with thorough assessment. We also contribute to the broader community by participating in complex needs panels and assisting with government and nongovernment organisations to assist with the management of complex clients. Recently, we won a contract through the Primary Care Partnership, to develop a complex needs panel, with 12 service providers, to manage some of the most complex needs clients between the ages of 17–29 years. (Medium-sized service)

We provide services to young people aged 12–25 that have coexisting mental health and AOD. We provide therapeutic case management, counselling, housing support & a social group. We work from a strengths-based approach and employ a number of therapeutic models including Narrative Approaches, CBT & psycho-dynamic. A large percentage of our client group is Aboriginal. We work primarily with individuals but also with family and extended family whenever possible. We spend a lot of time negotiating care plans with state health and collaborate and partner with a number of agencies. We directly partner with Headspace and employ a number of clinical psychologists at our site from that funding & in collaboration with [name of a network of services]. Our treatment program is provided in a youth work setting with a range of other services including: Late night transport service, Juvenile Justice Program, Aboriginal Casework & Counselling program, Education Programs for marginalised young people and we are located next to a skate park in [name of suburb]. Clients of the service are voluntary and this has a major impact on their readiness for positive change. One of our goals is to ensure that young people with emerging mental health problems are properly informed and educated about their illness and that it doesn't cause traumatising stigma. Secondly we have developed strategies to ensure that we can work with young people that are drug affected and present comorbid issues. (Small service)

Eleven of the services that participated in the evaluation are part of a larger organisation, while six are stand-alone services. Table 7 notes the type of parent organisation.

Other services provided by the parent organisation include acute health services, community health services, social support or welfare services, housing services, clinical mental health services, division of general practice, early childhood services, aged care services, cultural events, vacation care, ethnic school, and English classes (see Table 8).
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Table 6: AOD service: Treatment type

Type of treatment provided Response frequency
Counselling
9
Information
8
Assessment
7
Rehabilitation
7
Support
7
Withdrawal management/ detoxification
4
Pharmacotherapy
3
Other
4

Table 7: Type of parent organisation

Parent organisation Response frequency
Public hospital/ health care network
3
Welfare organisation
3
Church organisation
2
Community health service
1
Youth service
1
Peak Ethnic Community Centre
1
Total
11
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Table 8: Other services provided by parent organisation

Type of service provided Response frequency
Social support or welfare services
8
Housing services
8
Community health services
7
Acute health services
2
Clinical mental health services
1
Division of general practice
1
Early childhood services
1
Aged care services
1
Cultural events
1
Vacation care
1
Ethnic school and English classes
1

Residential services

Of the nine services that provide residential services, these range in capacity between eight and 70 beds. Table 9 below provides further detail.

The average occupancy rates during the last 12 months ranged from 67% to 95% (mean and median 82%). Services reported the shortest client stay as being less than a day to two days (mean 1.3), while the longest stays ranged between 16 days and 19 months (mean 180 days, median 103 days).

Table 9: Capacity of residential services

Number of beds per residential serviceResponse frequency
1–10
1
11–20
2
21–30
2
31–40
1
41–50
2
51–60
0
61–70
1
Total
9
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Community-based services

Twelve of the 17 services provide a community-based/outpatient service. These employ between three and 116 staff who provide clinical services. AOD services are slightly more likely to provide communitybased services than combined services (see Table 10 below).

The average active case load per equivalent full-time (EFT) staff position is between 12 and 20 (mean 16, median 15). The average length of treatment ranged from 12 to 180 days (mean 70, median 60). However, only six respondents provided data for average active case load and length of treatment.

Client groups to whom services are provided are listed below (response frequency in brackets):
  • Adult men (9)
  • Adult women (9)
  • Adolescent males (12)
  • Adolescent females (12)
  • Women with children (7)
  • Families (10)
  • Children (unaccompanied) (3)
  • Aboriginal and Torres Strait Islanders (8)
  • Non-Aboriginal (5)
  • People from culturally and linguistically diverse backgrounds (7)
  • People with physical disabilities (3)
  • People with intellectual disabilities (3)
  • People with an AOD problem (13)
  • People with a mental illness (7)
  • People with both an AOD problem and a mental illness (15)
  • Health professionals (1)
  • General population (1)

Table 10: Service type and provision of community-based services

Service type Provides community-based service
n (%)
Does not provide community-based service
n (%)
Total
n (%)
AOD
8 (73)
3 (27)
11 (100)
Combined
4 (67)
2 (33)
6 (100)
Total
12
5
17 (100)
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Drugs of concern

Sixteen services identified drugs of concern that their clients report. Of these, alcohol (n=16), cannabis (n=15) and amphetamines (n=13) were the most commonly nominated. Other drugs of concern included heroin (n=8), benzodiazepines (n=6), ecstasy (n=6), nicotine (n=5), methadone (n=2), and solvents (n=2). One respondent nominated Subutex (prescribed and non-prescribed, injecting).

Fourteen services reported that they specialise in the treatment of disorders associated with a particular substance. However, only two specified the substance(s). These include an amphetamine treatment service that is currently being established and pharmacotherapy for opioid replacement.

Diagnosed disorders

Services that cater for clients with a mental illness were asked about the disorders diagnosed in their clients. Thirteen agencies provided information about diagnosed disorders. The most common disorders include anxiety disorder (n=13), mood disorder (n=13), personality disorders (n=12), and substance use disorders (n=12). See Table 11 below for more detail.

Fifteen agencies advised that they specialise in the treatment of a particular mental health disorder. However, only two respondents specified the disorders. One service noted that they specialise in all the disorders mentioned above, and the other noted that 'MH service particularly works with psychosis and severe mood disorders. AOD works with anxiety disorders, PTSD14 and mild-moderate mood disorders'.

Fifteen services provided data on the prevalence of comorbidity in their clients. The percentages ranged from 35 to 100 (mean=72, median=75). In regard to service type, combined services (n=5) all reported comorbidity of 75% or higher, while six out of the 10 AOD services reported proportions below 75%. The range of comorbidity in clients reported by AOD services was between 35% and 86%. Our literature review found that 50% to 75% of AOD clients are reported to also have a MH problem (Cherry, 2007).

Table 11: Disorders diagnosed in clients

Disorders diagnosed in clients Response frequency
Anxiety disorder
13
Mood disorders
13
Personality disorders
12
Substance use disorders
12
Psychotic disorders
10
Dissociative disorders
5
Eating disorders
5
Adjustment disorder
4
Impulse-control disorders
4
Sleep disorders
3
Sexual disorders and dysfunctions
2
Somatoform disorders
2
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Philosophy and guiding principles

A range of different philosophies and approaches are noted in the literature, as well as the observation that available research has paid little attention to the role of program philosophy in regard to variations of service delivery (McCarty et al., 2008).

The survey asked respondents to describe the philosophy or guiding principles of their programs. The most commonly suggested principle was harm reduction or harm minimisation (n=11). Only one service, a therapeutic community based on the work of The Buttery in NSW, reported an abstinence approach. Working in a holistic (n=6) or flexible, client-centred (n=4) way was reported by several services. Team work, partnerships and resource sharing was noted by three services. Others reported not only working with individual clients, but also including families and/or communities (n=2). The latter comprised community awareness raising, community development, and advocacy work. One service noted Christian values. Further, evidence-based work (n=1) and best practice principles (n=1) were highlighted. Given the emphasis in government policies on evidence-based treatment, it is somewhat surprising that this was not mentioned more frequently.

A youth service detailed its narrative approach in the following way:

The concept of normality is something our team likes to deconstruct, unpack, and pull apart.... A lot of work revolves around the different meanings young people hold about their identity. Sometimes we find that young people try really hard to find a place to fit under the bell-shaped curve so that they can feel safe, so that they can feel secure, so that they can feel accepted. However, these young people often present as exhausted... exhausted from trying to make themselves fit. Sometimes we also find that young people will do anything to make sure they are not under the bell-shaped curve of normality. They are keen to do their own thing and stuff the system, stuff social norms and social expectations. However, when they realise they don't stand under the curve, for whatever reason, it comes at a cost to them. If they don't comply with what society wants, or what the normalising treatment is trying to achieve, the young people feel a sense of punishment and rejection. We aim to make our clinical practice non-pathologising and try to get away from the labels that are often given out. We work holistically and hope to honour the expression of lived experience—without prejudice, without judgement, and without a load of advice giving. Curiosity drives our work and our therapeutic relationships with young people. It's the genuine interest in their lived experience. Not so much in their drug choice or their mental health diagnosis.
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Framework/model used to classify comorbidity

The literature review found that there is no consistent conceptualisation of comorbidity. The comorbid population is not homogenous and there are often important clinical differences found between comorbid people in psychiatric or in substance use treatment settings (Manning et al., 2008).

The classification scheme made up by the five diagnostic categories (axes) provided by the DSM-IV15 are used widely in assessment of comorbidity and in research around comorbidity. Axis I covers clinical disorders that include major psychiatric disorders and diagnoses such as psychoses and mood disorders. Axis II categorises personality disorders and mental retardation. Substance use disorders are part of Axis I, with two mutually exclusive sub-categories: substance abuse and substance dependence (Centre for Addiction and Mental Health, 2002, p. 7). However, reflecting the diversity of the comorbid population, a number of frameworks for assessing or categorising comorbidity are in use.

Survey respondents were asked whether they use a classificatory framework or model for comorbidity. Three respondents reported that they use such a model, 11 advised that they did not use a model, and three were unsure what the question meant. The three services that used models or frameworks described these and their clients in the following way:
  • Model: 'Collect data as part of DHS minimum data set–reviewed quarterly by management team. Information is used for service planning. Routine use of validated screening and assessment tool Part of client ITP' — Clients: '40% currently screened 50% diagnosed with mental illness 80% self report mental illness Mental health disorders typically encountered–depression, anxiety, schizophrenia, paranoia, drug induced psychosis'.

  • Model: 'DSM IV criteria,–Axis I (primary diagnosis–clinical disorders) Followed by Axis II (personality disorders/mental retardation) Axis III (general medical condition) Axis IV (psychosocial and environmental problems)' — Clients: 'At present, there are a large majority of clients in Axis I (roughly 70%). These clients also fit Axis II due to personality disorders'.

  • Model: 'Level of disability or disturbance measured with the degree of addiction and dependence on any given substance' — Clients: 'Schizophrenics with cannabis addiction. Depressed clients with alcohol dependence. Personality disordered clients with morphine addictions etc.'
Three of the services that reported not using any models or frameworks for comorbidity provided further comment, indicating that they use comorbidity models or frameworks informally. They made the following comments:

Again depends which agency & service sector. For me the principle predominant cohorts by service settings are: General practice: persons with non dependant, abuse type SUDs16 co-occurring with high prevalence mental health disorders or symptoms. AOD service settings: Persons with dependant type substance use disorder frequently co-occurring with symptoms (or disorders) of Anxiety or Depression / high prevalence also of co-occurring PTSD and Personality Disorder Mental Health settings: Persons with severe, low prevalence type mental health disorders frequently co-occurring with a wide range of co-occurring SUDs (often only meeting criteria for Abuse but, nonetheless, with significant impact on the course and severity of their mental health disorder).

The DHS recommends the use of the three-tiered pyramid schema (illustrating the systematic response to dual diagnosis) where community health service settings ... are expected to mainly manage clients in tier 1 (lower severity MH and lower severity AOD problems) and clients from tier 2 (severe substance use disorder with or without lower severity MH problems). In reality, we also accept and manage clients in tier 3 (severe MH disorders/problems or low prevalence high impact disorders such as schizophrenia, and problematic AOD use) as long as they are not acutely unwell.

We don't formally use a framework, however we would consider the population of DD clients in MH and AOD services different. In AOD they tend to have high prevalence MH disorders, complex trauma and undiagnosed personality difficulties. In MH services they have severe mental illness plus substance abuse/dependence etc.

Overall, answers to this question reflect the diversity of frameworks for assessing or categorising comorbidity that was noted in the literature review.
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Consumer participation and client feedback

All respondents reported having formal or informal processes for client feedback in place. Formal client feedback processes included client surveys at specific times (e.g. at the end of treatment or every six weeks) or 'focus groups run periodically', client exit interviews, weekly feedback sheets, weekly feedback groups for residential clients, fortnightly case reviews with the client present, 'morning meetings held daily', and 'follow-up surveys during aftercare'. Further initiatives included a client committee to provide feedback to staff, a client quality improvement committee, consumer participation in planning and development of programs, and consumer representatives. Several respondents reported having complaints processes in place, a Client Charter, or consumer liaison staff. One services noted an 'open door policy at all times'. Informal feedback mechanisms included suggestion boxes and 'ad hoc verbal feedback'. One person suggested that well-developed formal mechanisms are in place in the MH sector, but 'less so in AOD'. Suggestion boxes and client feedback forms were reported most frequently.

Footnotes

14 Posttraumatic Stress Disorder
15 Diagnostic and Statistical Manual of Mental Disorders
16 Substance use disorders