There are both shared and distinctly different policy and practice issues regarding mental health and alcohol and drug addiction treatment services. Long-standing barriers to uniting addiction and mental health services range from the historical to the ideological to the practical, as Larry Davidson and William White point out in the April 2007 issue of theJournal of Behavioral Health Services and Research.
1 Despite the barriers, emphasize Davidson and White, “There has been and continues to be a clear consensus in the field that integration is both sorely needed and long overdue.”
It is as chronic medical conditions, with distinctive definitions of recovery, that addictions and mental illnesses must come together. We can strengthen public perception that freedom from addiction and mental illness is integral to overall health—and we can gain momentum in our advocacy for parity—only if the addiction and mental health advocacy communities unite. And we must not forget that discord between the communities also has a negative clinical impact, especially on people with co-occurring disorders.
Addiction and mental disorders have much in common. Both have endured a difficult past and are still subject to significant discrimination, including criminalization of behaviors associated with the disorders. Addiction and mental illness are highly treatable and impose a significant economic burden if untreated. Both depend heavily on public funding. And both are still not seen as an integral part of health care on the policy and practice side.
Those diagnosed with addiction disorders as well as mental illnesses face discrimination in coverage of treatment costs, whether through private insurance or public funding. According to a June 7, 2007 analysis published in Health Affairs, employer-sponsored coverage for substance abuse treatment continues to include annual and lifetime limits on treatment visits and inpatient days and also requires higher cost sharing than coverage for general medical care.2 Jon Gabel of the National Opinion Research Center and colleagues found that in 2006, 88% of workers with employer-provided health insurance had some coverage for addiction problems, but only 19% had plans that offered unlimited office visits and hospital stays, as is typical in other areas of healthcare. Gabel and colleagues estimated that deductibles for addiction services averaged 46% higher than those for medical and surgical conditions.
The analysis also stated that many workers are exempt from state mental health parity laws aimed at bringing private-sector mental health benefits more in line with coverage for other types of disorders. As a result, as of 2003, only one-fifth of U.S. workers with employer-sponsored health insurance were covered by “strong” parity laws mandating mental health benefits, prohibiting arbitrary limits on outpatient visits and inpatient days, and limiting the extent to which enrollees can face higher cost sharing for mental health services.
Although federal parity legislation for both addiction and mental health has been introduced for the first time this year in both the Senate and House, we still have a long way to go before addiction and mental illness are truly recognized as specialties of healthcare. We have a better chance of success if the two communities overcome traditional discord and come together based on their many commonalities.
Practice, policy considerations
A shared vision of how our behavioral health system should look and how it should be funded would help to reduce territorial fighting between the addiction and mental health fields. On the practice side, Davidson and White recommend the process of recovery, healing, and community inclusion as a new organizing principle for bringing the two worlds together. They point out that for both addiction and mental disorders, recovery is an individualized process of growth unfolding along a continuum, with multiple pathways leading to recovery. Persons in recovery from both types of disorders are active change agents, not passive recipients of care. With a shared definition of recovery—as the opportunity to lead a meaningful, productive life— addiction and mental health have much to learn from each other, but also already have much in common.
In order to bring cohesion to the two fields, mental health policy makers and practitioners need to learn about differential diagnosis related to substance use disorders. The behavioral health field tends to overuse the term “substance abuse.” There is a difference between abuse and addiction, and it is important to understand it if providing both addiction and mental health services. While a person with mental illness might be using alcohol or drugs inappropriately to “treat symptoms,” a person who is addicted needs addiction treatment, not a lecture on substances' harms.
At the same time, addiction policy makers and practitioners need a better understanding of the dynamics of mental illness and how they influence their clients' recovery. Even depression that is short of major depression can profoundly affect a newly recovering client. Medical intervention may not be the first treatment of choice, but medications offer powerful tools in keeping a person in treatment longer—still the best predictor of success.