Comorbid Disorders and Integrated Care Models

Prevalence, Risks, Costs and Treatment Outcome

People struggling with mental illness are more vulnerable to substance addiction and alcohol misuse. Those with a severe psychiatric illness have an even higher vulnerability to risky behavior and addiction,  with a predicted early morbidity of 25 years when compared to the general population. Coupled with a high prevalence rate of more than one co-occurring chronic medical disease, the encompassing treatment needs of this population of focus require a carefully constructed care coordination treatment model that is multi-disciplinary and focused on the use of evidence-based practices/EBP. For providers with training, cultural sensitivity and a wealth of experience treating this high risk, high need population, the clinical competency and focus on co-occurring and comorbid disorders is not a chicken or egg question. Blended knowledge and competency to address all clinical and health needs are woven into assessment, treatment planning, collaboration, engagement and outcome.  

How are those new to integrated care to approach this knowledge base? Are primary care providers ready to practice relapse prevention strategies? Does the CASAC provider know the range of high blood pressure? Are these teams ready to approach shared treatment planning? These are critical questions in the practical application of integrated care. Reaching Healthy People 2020 goals will be challenged by the potential of relapse, non-adherence to medication, treatment attrition, high emergency care use, and risky behavior affecting the treatment stability of emotional and medical wellbeing. 

It is important to understand that comorbidity is "When two disorders or illnesses occur in the same person, simultaneously or sequentially...also implies interactions between the illnesses that affect the course and prognosis of both." From the 2013 National Survey on Drug Use and Health: Mental Health Detailed Mental Health Tables, half of illicit substance users have some type of mental illness with varying degrees of symptom severity. While it is clear that individuals with a mood disorder have a particular vulnerability to addiction, those with a post-traumatic stress disorder, attention deficit hyperactivity disorder or a severe psychotic spectrum disorder also have a high risk of comorbidity and co-occurrence with any of the 25 identified CMS chronic diseases.  

Secondly, treatment engagement for comorbid and co-occurring disorders not only encompasses relapse prevention for addiction and medication adherence. A thorough understanding of the individual's functional abilities, stress coping skills, and life style management should be coupled with resiliency-focused interventions to improve engagement, health awareness and adaptive strategies for healthy choices and motivation. Use of EBPs grounded in cultural congruency is also of utmost importance. Indeed, the 12-step model is not always part of treatment success for certain populations and cognitive restructuring of maladaptive thoughts needs to take into account functional and developmental abilities of the individual. For example, helping an HIV patient establish healthy nutritional awareness may mean drinking a nutritional supplement with them while ascertaining stress reaction to the need for pill management, self-care and trauma processing. 

Success with population health goals cannot be measured by prescription refills alone, but by motivation to change, effective coping patterns and openness to the treatment team in times of distress and uncertainty. Implementation of integrated care for individuals with comorbid and co-occurring disorders must allow for ongoing dialogue to evoke the personal change needed to support attainment of population health goals.