According to a 1998 study by the US Department of Justice, approximately 16 percent of state prisoners and local jail detainees had a mental illness. Of these, 72 percent also had a co-occurring substance abuse disorder. ^[1]   While only 48 percent of adults in the general population who have both disorders received any type of treatment (mental health or drug or alcohol treatment) in 2002, only 11.8 percent of this group received services for both disorders. ^[2]   Because individuals in prisons and jails who have co-occurring substance abuse and mental disorders constitute a large population with distinct characteristics, considerable attention has been and should be paid to the development of appropriate and effective approaches to serving their particular needs. Policymakers and treatment providers should seek to improve rates and methods of treatment to support the ability of these individuals to prepare for release from prison or jail.

The question of how best to address the needs of prisoners with co-occurring substance abuse and mental health disorders fits into a broader discussion of appropriate treatment and systems models for all those who have these overlapping conditions. In 2002, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) submitted a Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders. ^[3]   The purpose of the Report to Congress was to outline the scope of the problem of treating people with co-occurring disorders and to describe current treatment approaches, best practice models, and prevention efforts. Compiled with assistance from a broad group of stakeholders, the SAMHSA report represents a significant attempt to achieve consensus on treatment issues that have been subject to debate. As the report notes, there is a significant lack of data on the prevalence of co-occurring disorders. In seeking to address the needs of this population, policymakers should promote research to ensure that the aggregate need is accurately examined.

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD) have developed a framework for improving coordination of services to meet the needs of each individual requiring services. ^[4]   The framework attempts to account for the fact that in some individuals, one disorder or the other-or both-may be more or less serious. Representatives of the two treatment systems agree that cases marked by high seriousness for both disorders require integrated treatment, while cases of lower seriousness in both disorders may best be treated in a general healthcare setting. When either the substance abuse disorder or the mental illness is clearly more disabling than the other condition, it is recommended that treatment be centered in the corresponding system. ^[5]   Through coordination of care models, the two systems can ensure that identification, engagement, and appropriate interventions occur in a timely and effective manner. Both the Report to Congress and the President's New Freedom Commission on Mental Health recognize the necessity of closer collaboration between the mental health and substance abuse treatment systems. ^[6]  

Individuals with co-occurring disorders have varied needs, which can be determined only through comprehensive assessment; there is no single prescribed approach to treating them. Policymakers and treatment providers should develop and utilize patient placement criteria to ensure that each patient is sorted to the most clinically appropriate type, level, and intensity of treatment. The range of effective interventions for people in prison or jail who have co-occurring disorders includes individualized, flexible treatment provided by well-trained staff employing a long'éäterm focus. Self-help and peer-support programs can be effective aids to successful treatment (especially when individuals transition back to the community), and therapeutic community models or cognitive behavioral methods can also be adapted for this group. (See Policy Statement 12, Substance Abuse Treatment for more on therapeutic communities and Policy Statement 14, Behaviors and Attitudes, for more on cognitive-behavioral therapy.) Whether such services are best provided through consultation between substance abuse and mental health providers, collaboration, or in a fully integrated model depends on the specific needs of each client. ^[7]   Cross-referral and linkage, cooperation, consultation, collaboration, and integration in a single setting or treatment model may each be appropriate strategies for different individuals.

Inevitably, treatment decisions will also be shaped by the constraints and resources of the systems involved, particularly in the correctional setting. To facilitate availability of a full array of programs, systems must be designed to include appropriate funding mechanisms that can support the continuum of services needs; address credentialing/licensing issues; and establish data collection/reporting systems, needs assessment, planning, and other related functions. Appropriate treatment for individuals with co-occurring disorders also involves service systems other than the substance abuse and mental health treatment systems. People with co-occurring disorders, particularly those in prison or jail, frequently have a wide range of other health and social service needs such as employment, benefits, and housing, all of which require attention during and after their incarceration if they are to succeed in the community. (See, for example, Policy Statement 15, Education and Vocational Training, Policy Statement 24, Identification and Benefits, and Policy Statement 19, Housing, for more on corrections and transitional social services programming.) Policymakers should develop and promote strategies to help services and systems, to function across their funding and jurisdictional borders. Restrictive federal, state, and local funding streams and regulations, in particular, present significant impediments to cooperation and integration between these systems. In working towards appropriate treatment for re-entering individuals with co-occurring disorders, policymakers and practitioners must examine ways to remove financial barriers to effective treatment. (See sidebar, "Coordinating Funding Streams for Comprehensive Service Delivery," in Policy Statement 4, Funding a Re-Entry Initiative)

An appendix to SAMHSA's Report to Congress examines financing of services for co-occurring disorders. It reports that studies on costs and cost-effectiveness of various types of treatment for co-occurring disorders yield mixed findings. One key challenge is that it is simply more expensive to treat a person with co-occurring substance abuse and mental disorders than it is to treat an individual with either disorder alone. People with co-occurring disorders-especially those with serious mental health needs-tend to receive more intensive treatment, often in hospitals or other inpatient facilities. Greater coordination in the provision of treatment to those relying on multiple systems, however, may result in overall cost reductions.

Of course, this assumes that individuals with co-occurring disorders are receiving treatment. In many instances, it is people who are not in treatment who enter jails and prisons. Thus, correctional facilities bear the cost of the unavailability of appropriate treatment in the community. In essence, they often act as the gateway to services for first-time clients whose presence adds costs to the system.

Critical to understanding the costs and cost-effectiveness of treatment for co-occurring disorders is the ability to understand the needs of the individuals in treatment. It appears that savings derived from collaboration and integration are more pronounced in cases involving more serious forms of mental illness. Where less intense treatment for mental illness is involved, the savings stemming from some form of integrated treatment may not be as high. Researchers caution that there is much more to be learned about both the cost-effectiveness of specific interventions for co-occurring disorders and the cost-offsets to be realized in service systems such as corrections or probation and parole.

Example: Vermont Department of Health Division of Mental Health and Office of Alcohol and Drug Abuse Programs and Vermond Department of Corrections

The Vermont Department of Health Division of Mental Health and Office of Alcohol and Drug Abuse Programs and the Vermont Department of Corrections have collaborated in an effort to coordinate programming more effectively for individuals with co-occuring disorders who are involved with the criminal justice system. The program promotes public safety and public health by providing comprehensive substance abuse and mental health treatment to the individuals in the criminal justice population. The program includes individualized substance abuse treatment; a phase-oriented, motivational enhancement approach; stage-wise groups; and teams that are composed solely of clients with co-occurring disorders who are involved in the criminal justice system.