Science and Service: Opening Pathways to Better Mental Health
Richard K. Nakamura, Ph.D.
Dr. Richard Nakamura, deputy director of the National Institute of Mental Health (NIMH), explained that for purposes of the conference, the definition of behavior must be larger than individual behavior, to include the system of behavior through which care is delivered. Dr. Nakamura pointed out that the mission of NIMH is to reduce the burden of mental and behavioral disorders through research on the mind, brain, and behavior, and cited statistics from several World Health Organization surveys showing the extent of the burden. Nakamura
also discussed the new understanding of the brain—that our genes specify a general plan with many options. The brain changes its physical structure through behavior and interactions with the environment, integrating nature and nurture, mind and brain, genes and the environment. Nakamura discussed the process of neurogenesis in the adult brain and how this allows new learning throughout life. He also touched on impairments to neurogenesis, such as stress, anxiety, PTSD, depression, and childhood trauma. In conclusion, Nakamura explored the
implications for psychotherapy and pharmacotherapy and the development of new outcome models.
The Co-Occurring Matrix for Mental and Addictions Disorders
Richard K. Ries, M.D.
Dr. Richard Ries, professor of psychiatry at the University of Washington and director of outpatient psychiatry at Harborview Medical Center in Seattle, Washington, covered specifics of the Co-occurring Matrix. The matrix addresses two illnesses and systems—mental health versus addictions and low versus high severities, creating a four-quadrant conceptual framework for systems integration and resource allocation in treating individuals with co-occurring mental and substance abuse disorders. Ries explained several unresolved issues involved with using the matrix and pointed out that to date, no data exists for measuring outcomes of use. Ries also discussed the Harborview Health Services Research Group’s attempt to categorize approximately 6,000 patients into the four categories.
Co-Occurring Disorders: The “Z-axis”
Richard Saitz, M.D., M.P.H.
Dr. Richard Saitz, of Boston University and Boston Medical Center, discussed just what is meant by the term comorbidity and the confusion it causes for service providers, patients, and families. How do you diagnose comorbidity? What is the primary diagnosis—mental health, substance abuse/addiction, or medical condition? Saitz used several case studies to highlight the complexities this
causes in treating an individual with co-occurring conditions. Further, Saitz explored a “Service Coordination by Severity” conceptual framework proposed by SAMSHA and how to expand this framework to integrate medical care, or what Saitz refers to as the "Z axis"—medical severity. Saitz went on to present data on the risks for co-occurring disorders, such as alcohol-related emergency and hospital utilization; medical disorders more common in patients with substance use disorders, psychotic disorders, or both; and comorbidity in a detoxification sample. Saitz concluded his presentation by addressing how mental health/substance abuse comorbidity issues impact the care of chronic medical conditions and by presenting models of care for patients with co-occurring medical, psychiatric, and substance abuse disorders. Models of care included integrated primary care and addiction treatment, integrated medical and alcoholism care, and buprenorphine treatment in primary care.
Addressing Co-Occurring Conditions: A Provider’s Perspective
Joan E. Zweben, Ph.D.
Dr. Joan Zweben, professor of psychiatry at the University of California, San Francisco, and executive director of the 14th Street Clinic and East Bay Community Recovery Project,
presented a provider’s perspective to addressing co-occurring conditions. She outlined many of the services provided by the clinic, but enumerated the many obstacles to providing thorough, quality care. These obstacles include poor policy statements and poor communication between government entities, resulting in conflicting expectations and requirements between programs. Zweben called for policy statements to be collaborative (i.e., interagency) and to outline expectations for treating persons with Co-Occurring Disorders. Policies should also clearly identify the impropriety of excluding persons with Co-Occurring Disorders from either treatment systems or other service systems. Zweben also examined issues of training and licensing professional and nonprofessional care providers. She concluded by highlighting the need for a universal charting system to allow consistent data collection.