Treatment of Adolescents with Co-Occurring Mental Health and Substance Abuse Issues: (Original Work Peer Reviewed Published Article)

A Pilot Study to discover and Inform Best Practice    

(Identifying Information Deleted By Author [Me])

(Image Source: Anxiety And Panic Attack Treatment Tips)

Abstract

          This study was a mixed methods experiential subjective survey conducted in the (Somewhere In The USA) area.  The sample was taken from known (Mid-Size Community, USA) mental health and chemical dependency counselors. This study solicited, evaluated, and contrasted local area therapist's opinions regarding best practice in treating adolescents with co-occurring disorders. This study was conducted in the spring of 2009 by (james83501) The instrument was a twelve question voluntary convenience survey conducted entirely on-line. Results indicate that adolescent children presenting with co-occurring disorders is a relevant problem in the (Mid-Size Community, USA)  This study further indicated that treating each disorder simultaneously and family participation in the continued care of the child are equally important for treatment success.   

Introduction  

          Effective treatment of those with substance abuse and/or mental health issues has long been a national concern of social workers and mental health practitioners.  In fact, recent studies have shown that more than 50 percent of those presenting with substance abuse disorders have an underlying mental health disorder as well (Harris & Edlund, 2005). It has often been shown that those with substance abuse/mental disorder co-morbidity have been suffering from their mental disorders prior to resorting to self medication by way of substance abuse (Wu, Hoven, Okezie, Fuller, & Cohen. 2007; Diamond, Panichelli-Mindel, Shera, Dennis, Tims, & Ungemack. 2006; Chater, 2004).  It is commonly believed that those suffering from mental disorders are self-medicating to cope with the pain associated with it (Harris & Edlund, 2005). It is further thought that when mental illness is properly treated, the rate of substance abuse declines significantly, but that concentrating on treating the substance abuse issues only, results in higher rates of mental illness (Harris & Edlund, 2005).   

According to the Substance Abuse and Mental Health Services Administration (SAMHSA) report dated May 2003, there are approximately ten million Americans presenting with dual mental illness and substance abuse disorders and that dual diagnosis is the rule instead of the exception (Bender, 2003). According to a follow-up SAMHSA report dated April 2005, it was found that those with dual diagnosis look upon their disorder(s) as a singular malady, and often are treated for only one of their diagnosis. Such individuals with dual diagnosis regularly go untreated. As a result of these findings, SAMSHA is calling for a five-year program addressing the need for agencies from federal, all the way down to state, and local service providers to become involved in a reorganization of how services are provided to those with dual diagnosed disorders (Barlas, 2005).

    Clients with co-morbid mental health and substance abuse issues often end up slipping through the cracks, and as a result, go untreated or poorly treated. One of the reasons may be that there is little or no coordination between mental health and substance abuse practitioners. Practitioners often quibble as to whether the substance abuse caused the mental disorder or vice versa, usually concluding with the mental health practitioner preferring not to deal with substance abusers, thus making effective treatment a difficult proposition. These clients typically experience several failed attempts at drying up (chemical dependency rehabilitation), yet the underlying mental illness has gone untreated, resulting in perpetuation of the problem (Chater, 2004).

    Those presenting with co-morbid substance abuse and mental illness often self-medicate with contraband drugs thereby endangering them with the risk of incarceration. The rigid court systems in most states are hard on drug offenders resulting in many with co-occurring disorders spending time in prison where there is little help available to treat these individuals. This failure to treat such individuals exacerbates the problem and upon their release the cycle starts all over. These unfortunate people, again, seek to self medicate as a result of untreated mental illness. This is an example of how untreated mental illness along with the co-morbid substance abuse can lead to an expensive merry-go-round of repeat offenders bogging down the court system needlessly at a substantial cost to society (National Mental Health Association, n.d.).

  Since the move toward managed medical care starting in the Nixon era, funding has become a function of restrictive policy rather than best practice. With managed care, came the profit-driven idea of limited treatments for mental illness (the medical model of treatment) where individuals, including children and adolescents, typically are limited to 10 “treatments” to correct their “disease.” This model divides mental illness and substance abuse into separately occurring disorders where there is little chance that an individual with co-occurring disorders, seeking help for mental illness, would also get help with substance abuse (Agrawal, & Veit, 2002). Likewise, a dually presenting individual being treated for substance abuse, may never receive treatment for their mental illness, or be required to successfully complete substance abuse treatment before qualifying for mental health treatment. Being excluded from further treatment is ineffective for individuals in this type of substance abuse program, who frequently relapse to self-medicate their untreated mental health issues (Olmstead, White, & Sindelar, 2004).

    How have the new SAMSHA guidelines for the improvement of mental health and substance abuse treatment affected (Some State, USA) citizens? The (Some State, USA) adheres to more restrictive policies of past paradigms that offer little to those with dual diagnosis, including children and adolescents, which often leads to misdiagnoses, relapse, poor performance in school, family crises, and interactions with the Department of Corrections. Funding for mental illness and substance abuse is, in many cases, limited, and policy mandates opting for the less expensive route overseen by regional mental health advisory boards (Health Care Task Force, 2004).

        Ideologies for this approach based on cost savings may be misplaced. Research indicates that mental illness is often a cause of substance abuse (Wu, Hoven, Okezie, Fuller, & Cohen. 2007; Diamond, Panichelli-Mindel, Shera, Dennis, Tims, & Ungemack. 2006). Those individuals trapped in a cycle of relapse contribute to a re-occurring societal and financial problem. This problem would be better dealt with utilizing a best practice approach rather than the managed care style approach utilizing regional advisory boards (Health Care Task Force, 2004).

        Studies have shown that there is a strong relationship between substance abuse and pre-existing psychological and/or psychosocial issues in children and adolescents. One study shows that children and adolescents self medicate for depression (Wu, Hoven, Okezie, Fuller, & Cohen. 2007). Another study indicates a positive correlation between severe psychological troubles, and self-medicating with drugs and/or alcohol (Diamond, Panichelli-Mindel, Shera, Dennis, Tims, & Ungemack. 2006).

Relevant Research

Brief history

          Historically, concerns about the inadequacy inherent in mental health and substance abuse treatment are just a sub-class of broader shortfalls of the health care system in general. In the pre-managed care era, physicians operated mainly on a proprietary basis with the wealthy having access to better treatment, and the poor being at the mercy of good-hearted doctors and some benevolent individuals. Treatment for mental health and substance abuse was lacking for the same reasons (Agrawal & Veit, 2002).

         Movement to the Kaiser-Permanente’ model of the “health maintenance organization,” during the Nixon era, was a veiled attempt at national health care in that, in reality, it was a movement to incorporate medicine into a big business structure where keeping costs at a minimum was a priority. This movement eventually evolved into the modern “managed care” model where medical boards decide whether one qualifies for certain procedures based on their determination of “medical necessity” (Agrawal & Veit, 2002).

       Due to the nature of mental illness and substance abuse disorders, treatment is a costly proposition for managed care. Even with research showing that extended care reduces relapse, current versions of managed care schemas often limit mental health and substance abuse treatments to ten or less sessions (Olmstead, White, & Sindelar, 2004). Since mental health and substance abuse issues are particularly expensive, many services that could improve the lives of those with mental health and substance abuse disorders are dropped (Olmstead, White, & Sindelar, 2004).

          Haris and Edlund (2005) conclude that a great number of those with substance abuse disorders, self-medicate because of an underlying untreated mental illness, which leads to their co-occurring disorder. The knowledge of the phenomena of dual diagnosed disorders has subsisted since the 1980’s. It is generally known that those with co-existent disorders are an at-risk population. Those in this population tend to have inadequate support systems and relationships. They tend to have sporadic housing and employment deficits, and are often unskilled and under-educated. These traits can lead to criminality as a necessity for survival. Other risky behaviors, such as needle sharing and unprotected sex can lead to high rates of Hep C, HIV/AIDS, STDs, and other maladies. The nature of possible behavioral traits, due to these untreated co-morbid disorders, can lead to unnecessary incarceration and other expensive alternatives, in an attempt to deal with this at-risk population (Johnson, Brems, Wells, Theno, & Fisher, 2003).

         Usually a dually diagnosed individual is passed back and forth between substance abuse and mental health practitioners who squabble about what came first, the mental health issues or the substance use/abuse issues. Ultimately the person with a dual diagnosis is severely underserved. They regularly are sent to substance abuse rehabilitation before or without mental health treatment. This can lead to the worsening of their condition as now they are not able to self-medicate, nor be properly diagnosed and treated by a mental health professional. Instead of experiencing improvement in their condition, they suffer risk of becoming one of the many homeless, helpless individuals.

         As early as 2003, the Substance Abuse and Mental Health Administration (SAMSHA) has advocated for research pertaining to the insufficient and relatively unattainable resources those with dually diagnosed disorders have access to (Bender, 2003). As a follow-up to studies resulting from this, SAMSHA delivered a report in 2005 with findings showing that those with co-occurring disorders clearly benefited from concurrent mental health and substance abuse treatment. These benefits included a possibility for a higher rate of recovery and even prevention of debilitation and/or impairment (Barlas, 2005).

         The major problem with the mental health and substance abuse system is the breakdown of service coordination, or in other words, treatment is fractionated. States and local agencies dissociate between substance abuse and mental health issues. There are ongoing disagreements as to who should initially be responsible for treating dual diagnosed consumers and where the funding would come from. This dead-lock is causing an increasingly alarming trend for at-risk individuals to succumb to behavior that ultimately costs society considerably. Evidence suggests that a fractionated system of treatment has existed in dealing with these individuals, and there is good reason to believe that cross training between mental health and substance abuse practitioners and an overhaul of current policies has been well overdue (Chater, 2004).

          Recent studies show that the concurrent method of treatment for these individuals has been most effective in preventing this trend and even lessens the time it takes for a dually diagnosed person to recover (Chater, 2004). This highlights potential savings to the healthcare system (in fewer ER visits for example). The result of concurrent treatment is the lessening of the likelihood of the court system needing to deal with offenders (Lee, Morrissey, Thomas, Carter, & Ellis, 2006).

         Many individuals must resort to state and federally funded Medicaid for treatment, though they are faced with limited program availability (National Mental Health Association, n.d.). One recent report, from the National Mental Health Association (NMHA), states that the fragmentation of services for many state and local agencies is due to lack of coverage from managed care systems, rigid policy mandating treatment of substance abuse issues prior to mental health issues, required involvement in 12-step programs, and penalizing those who relapsed by prohibiting treatment.

         In short, funding for mental health and substance abuse treatment is sparse. NMHA advocates for more state funding, larger Medicaid program availability, Federal Block Grants for mental health, availability for those with dual diagnosis to access Temporary Assistance to Needy Families (TANF) programs to help them and their families during recovery, as well as other federal grants to revamp existing treatment policies and educating state and local agencies so that they are well versed in how to appropriate funding for these services. Ultimately, NMHA is advocating that mental health and substance abuse treatment facilities reach common ground and come up with plans to develop adequate services (National Mental Health Association, n.d.).

Review

         In (Some State, USA), mental health and substance abuse issues have been bandied about in the state Legislature. There is a Health Care Task Force committee that discusses possible ideas/actions to address state of (Some State, USA)’s shortcomings in the area of mental health and substance abuse (Health Care Task Force, 2004). However,  to date there has been no decisive legislation mandating compliance with SAMHSA guidelines for mental health and substance abuse issues, though there have been deliberations by this committee about how best to revise the current mental health and substance abuse system and how to pay for it. Recent legislation is geared to encourage local governments and entities to develop regional plans that address local needs. This legislation does not provide for funding. Most dually diagnosed individuals, in the state of (Some State, USA), still rely on limited services provided by local managed care facilities and independent agencies that bill third parties for limited care and the restrictive services provided through the State Mental Health Board, and (for the severely mentally ill only) Assertive Community Treatment (ACT) teams (Health Care Task Force, 2004).

         The (Some State, USA) Health and Welfare’s ([SS]HW) “reduction plan” eliminated administrative positions in their mental health program which were responsible for administering funding for both, child mental health, and adult mental health services. Funding for those programs was not lost, (SS)HW just failed to spend funding set aside for mental health programs. (SS)HW claims that the funding was redirected to other mental health and substance abuse entities in the private sector, but proof of this does not exist. (SS)HW claims that the receipts were lost. In short, the state of (Some State, USA) Health Care Task Force has deliberated many possibilities, such as talk of the necessity for a shift of emphasis toward best practice. However, subsequent legislation for such has no effectiveness due to lack of funding (Health Care Task Force, 2004).

       The state of (Some State, USA) falls far short of the SAMHSA guidelines for restructuring how mental health and substance abuse issues are dealt with (Mental Health America, 2008). A few areas in which (Some State, USA) falls short include:  

• Approximately 10% of adolescents have had at least one major depressive episode in the past year (highest bracket in the nation).   
• (Some State, USA) ranks 45th (sixth above the very worst state) for depression. 
• (Some State, USA) is in the second highest bracket in the nation for the most potal health days for adults per month. 
• (Some State, USA) is in the highest bracket for suicides per 100,000 people. 

         (Mental Health America, 2008)

         A common sense approach to dealing with co-occurring disorders in the state of (Some State, USA) should start at the beginning—treating children and adolescents for these disorders before they become adults. Russell states that intensive youth therapy programs that isolate the young person from their normal environment have a significant positive effect on treatment of co-occurring disorders in youth (2005). There seems to be no statistical difference between outcomes of programs with shorter terms (as in 21 days), as compared to those with longer terms (as in two months or longer). However, follow-up outpatient treatment was shown to be important in a successful treatment strategy (Russell, 2005). Russell’s studies have also shown that the mean effective age group of adolescents is ages 12-15 (Russell, 2005). However, this could be because youth from ages 16-19 entered these studies with “higher behavioral distress” and therefore end of study measurements were of a lesser degree of differentiation (Russell, 2003).

        Adolescent drug courts have concentrated their efforts mostly on drug rehabilitation. Due to the multifaceted complications in treating adolescents, such as mental health and environmental issues, there needs to be more studies showing their effectiveness in treating youth offenders (Bryan, V., Hiller, M., Leukefeld, C. 2006). In a 2006 article Bryan et al, states the best chance for treating these young individuals would take an interactive inter-agency effort (Bryan, et al 2006). Some suggested program modalities include Individual supportive therapy and/or specialized psychotherapy, family and/or group therapy, crisis intervention, and other services and/or evaluations (Arredondo, D. E., et al. 2001). Bryan et al conclude that roadblocks for developing programs include funding, the lack of diversity of program choices that could work with the courts, and the need for better forms of early screening (Bryan, et al 2006).

Need for further research

         Questions that need to be asked: What kind of treatment for children and adolescents, in regards to best practice, will be effective for increasing the success rate for recovery and reducing the risk of relapse, thereby improving quality of treatment? And, how will such a program be funded? To answer these questions, one would be better to ask those who have had experience treating children and adolescents with co-occurring mental health and substance use/abuse issues, rather than those setting economic based policies.

         This study queried mental health and substance abuse practitioners with questions pertaining to their experience dealing with adolescents presenting with co-occurring mental health and substance use/abuse disorders, and what relationships they see affecting substance use/abuse and mental illness, as well as their opinions about current funding. The hypothesis was there will be a trend for mental health and chemical dependency practitioners in the (Two Mid-Sized Cities Located Close To Each Other) area to favor concurrent methods of treatment of adolescents presenting with co-occurring disorders, as opposed to fractionated methods of treatment—that treating adolescents for mental health and substance use/abuse issues concurrently, rather than treating each issue separately, is best practice.

Method

Purpose

  The purpose of this study was to seek out, understand, and identify possible alternatives to the existing (Some State, USA) policies of fractionated treatment for dually diagnosed mental health and substance use/abuse affected adolescents. Results from this study could be used as a subjective baseline to justify further studies into the matter (i.e. possible test programs, and best practice recommendations for treating adolescents presenting with co-occurring mental health and substance use/abuse issues).

Paradigm

  My personal philosophical grounding of paradigms in research includes taking a constructivist leaning toward an emancipatory approach (Author’s Note: Translation—A Good Program That Frees Up The Individual) to affect positive social change through liberation, and political action (Author’s Note: Translation—Stop Doing Useless Things Like Bureaucratizing Treatment Options), yet doing so with the belief that understanding comes from participants’ perspective, and judgment is based upon the consensus of participants and researcher. As a baccalaureate level social work student, I adhere to the (A National Group Of Counseling Professionals) Code of Ethics. One key principal in the code is to advocate for social justice (in this case, on behalf of dually diagnosed individuals) through advocacy, research, evaluation, and social action ([A National Group Of Counseling Professionals], 1999).

    My “constructivist” paradigm with “emancipatory” leanings was derived from reflecting on the way that humankind independently and actively creates their own individual schemas and realities through biopsychosocialspiritual interactions, combined with the realization that there are many that have not been able to access needed resources. My own personal development originates from many years in the “school of hard knocks,” congealing through my (Counseling Field) education and theoretical framework.

Study Design

         This study was a mixed-methods design employing quantitative and qualitative analysis. The goal of this study was to discover best practice and to inform and positively impact best treatment practice in the fields of mental health and substance use/abuse in regards to adolescent youth presenting with both issues.

Population and Sample

       The sample of this simple convenience survey was selected from the available practitioners from local mental health and chemical dependency treatment center(s) and independent practitioners in the (Two Mid-Sized Cities Located Close To Each Other) Valley. Administrators of local treatment center(s) were asked to make the survey available to qualified practitioners by forwarding an e-mailed invitation/informed consent for the survey. Independent practitioners were contacted directly by the researcher via e-mail, with an invitation/informed consent form, concerning participation in the survey. Those who responded to the invitation/informed consent made up the participating sample. Qualified individuals were defined as any independent practitioner or anyone in an agency, who is skilled in, and practices treatment or care for the agency’s clientèle

Investigative Techniques

        This study was a mixed methods survey design employing qualitative and quantitative analysis. Participants were provided an informed consent. There were no provisions anywhere in the survey for participants to divulge their identity(s) for reasons of anonymity.

Instrumentation

       The instrumentation was of this researcher’s own design. The outcomes of various treatment modalities on youth clientèle with co-occurring mental health and substance use/abuse issues described in the open ended experience and opinion portions of the survey, and the closed opinion question formed the dependent variable(s). The “satisfaction of treatment methods” LIKERT questions and the demographic questions determined the sub-types of independent variables.

         The questions for the survey were formulated based on evidence that the state of (Some State, USA) (in comparison to the state of [Some Other Nearby State] has not complied with the existing SAMHSA national guidelines for restructuring how mental health and substance abuse issues are dealt with on state and local levels, and; because of this fact, many individuals including area adolescents with co-occurring mental health and substance use/abuse issues may not be getting proper and/or effective treatment for their problems.

Data Collection

       The survey was administered entirely on-line, with an invitation/informed consent form sent via e-mail to the sample including an “accept” hyperlink to respond to. Those who consented to the survey, gained access to the on-line survey page and were able to participate in the experience and opinion questionnaire. They were then asked twelve mixed quantitative and qualitative questions. When the subjects felt that the survey was completed to their satisfaction, they were asked to click the “submit” button. They were then brought to a confirmation page from which they logged off.

       The on-line survey was designed to automatically send the respondent’s completed survey to a designated e-mail account. The respondents were given ten days to respond.  E-mail invitations to participate in the survey were followed up with one e-mail reminder designed to motivate the respondents, who had not already participated, to willfully and voluntarily comply with the invitation request.

Data Analysis Plan

       Upon completed survey submission, the data was compiled. Descriptive statistics and trends were analyzed, and the results reported to the (Some Mid-Sized City, USA) State College administration, teachers, relevant staff, and agency administrators for program evaluation.  

Ethical Consideration (Human Subject Protections)

        The institutional Review Board (IRB) at (Some Mid-Sized City, USA) State College reviewed and approved this study prior to implementation. Anonymity of participants was preserved due to the nature of this study having no provision for identity disclosure. Participation was completely voluntary and the participants were able, at any time, to choose to discontinue the survey by clicking on the “Clear Form” button provided at the bottom of the survey questionnaire, and then simply closing the window. If the participants had questions, concerns, or complaints regarding their rights, they were encouraged to contact Dr. (Name And Contact Information Deleted), or the Institutional Review Board of (Some Mid-Sized City, USA) State College.

Bias

       This researcher, presently, has no stake in policy or legislation in regard to this topic

Assumptions

   For this survey to have been truly representative of mental health and/or chemical dependency therapists in the local area of the (Two Mid-Sized Cities Located Close To Each Other) Valley, one must assume that the participants answered the questionnaire honestly and objectively. Also, this researcher took for granted that the surveys participants, by nature of their work, were and are compassionate toward their clientèle and seek the best methods of treatment for their client’s well-being.

Limitations

  This researcher, deliberately, did not research the economics of utilizing best therapy practices for those adolescents with mental health and/or substance use/abuse issues. However, future studies of economics could be researched by studying the effects of the results of possible test bed “best practice” model programs on societal costs. 

Results

Sample

       The participating sample is made up of local area (Two Mid-Sized Cities Located Close To Each Other) mental health and chemical dependency practitioners. A total of 10 subjects licensed and/or certified from the state of (Some Other Nearby State, USA) participated, and 4 subjects licensed and/or certified from the state of (Some State, USA) participated. It was hoped that a large enough sample from both states would have participated in the survey, so that there could have been a cross-comparison of data between each State. However, it was determined that there was too low of a sample from (Some State, USA) to make a relevant comparison.

(Tables Removed. The Process Of Uploading Them On Steemit Turned Them FUBAR)

Analysis

       In regard to qualitative data (questions 11 & 12): Participants asked to describe their experience in treating adolescents with co-occurring disorders (Table 7), as well as their opinion of what would be best practice in treating said population (Table 8). In Table 7, the data shows that over half of the survey participants reported having regularly worked with adolescents with co-occurring disorders. There were concerns in regard to client consistency in staying in treatment, as well as, poor selection or too restrictive of treatment options. In Table 8, there were two prevalent themes: mental health and substance abuse disorders should be treated simultaneously to be most effective, and; family involvement was important in treatment success.

Discussion and Implications

Discussion

  The demographics from this study show that this sample was well qualified and experienced, and therefore should be considered reliable regarding the answers they provided to this study’s survey. The findings of this study confirms this researcher’s hypothesis that there will be a trend for mental health and chemical dependency practitioners in the (Two Mid-Sized Cities Located Close To Each Other) area to favor concurrent methods of treatment of adolescents presenting with co-occurring disorders, as opposed to fractionated methods of treatment—that treating adolescents for mental health and substance use/abuse issues concurrently, rather than treating each issue separately, is best practice.

         The data in this study indicates a high percentage of mental health and chemical dependency practitioners believe that the number of adolescents presenting with co-occurring disorders is at an epidemic level (see Table 2), the current treatment available for that population is inadequate (see Table 5), and that co-occurring disorders should be treated simultaneously (see Table 8). One interesting finding was that family participation was a factor given equal importance with simultaneous treatment of co-occurring disorders (see tables 7 & 8). This is consistent with previous studies stating that family involvement should be a part of a multi-faceted approach to treatment (Arredondo, D. E., et al. 2001).

  The concern that current methods available for treatment of adolescents with co-occurring disorders are too restrictive goes along with findings in a report presented to (Some State, USA) State Legislators in 2004 in regards to (Some State, USA)’’s mental health and chemical dependency treatment policies (Health Care Task Force, 2004). The concern that there are no guidelines in regard to treating adolescents with co-occurring disorders (and because of this there is a general feeling of failing the community in this area) confirms, in many ways, a 2008 report that shows (Some State, USA) ranking so extraordinarily low in mental health and chemical dependency care when compared to the rest of the United States (Mental Health America, 2008).

Implications

  The findings of this study bring to light the need for changes in chemical dependency and mental health care in the state of (Some State, USA). If the small sampling of mental health and chemical dependency practitioners is representative of, and therefore consistent with, findings from a much larger sample, the findings of this study should be considered a cause for alarm in regard to the state of (Some State, USA)’’s current mental health care and chemical dependency policies. This researcher believes that larger, similar studies should be conducted to add to the (Some State, USA)’s body of knowledge on this issue. Perhaps more research would be then used to help promote change on a state-wide level. Comparative studies should be conducted looking at policies and procedures of other states that have been, to a greater degree, successful in treating this population.

References

          Agrawal, G. B., & Viet, H. R. (2002) Back to the future: The managed care revolution. Law and Contemporary Problems 65(4). Retrieved May 2, 2008 from http://www.law.duke.edu/shell/cite.pl?65+Law+&+Contemp.+Probs.+11+(Autumn+2002)

          Arredondo, D. E., Kumli, J. D., Soto, L., Colin, E., Ornellas, J., Davilla Jr., R. J., Edwards, L. P., Hyman, E. M. (2001). Juvenile mental health court: Rationale and protocols. Juvenile and Family Court Journal, fall issue. Retrieved November 21, 2008 from http://www.law.arizona.edu/depts/upr-intj/JMHCRationalProtocols.pdf.

          Barlas, S. (2005, April) SAMHSA progress on comorbidity policies. Psychiatric Times, 22(5), 26. Retrieved December 23, 2009 from ProQuest Social Science Journals (Document ID: 859519341)

          Bender, K. (2003, March) Integrated care for co-occurring disorders to become SAMHSA priority. Psychiatric Times 20(5), 65. Retrieved September 23, 2009, from Academic OneFile. (Gale Document Number: A100984137)

          Chater, D. (2004) Everybody's business but nobody's priority: improving the care of people with a dual diagnosis is the aim of a new training package launched by Rethink and Turning Point. Mental Health Practice 8(2), 10. Retrieved September 23, 2009, from Academic OneFile. (Gale Document Number: A123576190)

          Diamond, G., Panichelli-Mindel, S. M., Shera, D., Dennis, M., Tims, F., and Ungemack, J. (2006) Psychiatric syndromes in adolescents with marijuana abuse and dependency in outpatient treatment. Journal of Child & Adolescent Substance Abuse. 15(4). Retrieved September 23, 2008 from Http://www.haworthpress.com

          Harris, K., and Edlund, M. (2005) Self-medication of mental health problems: New evidence from a national survey. Health Services Research 40(1), 117. Retrieved September 23, 2009 from Academic OneFile. (Gale Document Number: A130649170)

         Health Care Task Force (2004) Committee minutes: Thursday January 15, 2004. State of (Some State, USA)  Health Care Task Force. Retrieved May 2, 2008 From (Website For Some State, USA)

        Johnson, M., Brems, C., Wells, R., Theno, S., and Fisher, D. (2003) Comorbidity and risk behaviors among drug users not in treatment. Journal of Addictions & Offender Counseling 23(2) pp 108-119. Retrieved September 23, 2009 from Academic OneFile. (Gale Document Number: A102792440)

        Lee, S., Morrissey, J., Thomas, K., Carter, W., and Ellis, A. Assessing the service linkages of substance abuse agencies with mental health and primary care organizations. American Journal of Drug and Alcohol Abuse 32(1), pp 69-87. Academic OneFile. (Gale Document Number: A144605254)

         Mental Health America (2008) Ranking America’s mental health: Analysis of depression across the States. Mental Health America. Retrieved May 7, 2008 from http://www.nmha.org/go/state-ranking

          National Mental Health Association (n.d.) State coalitions on coordination of treatment for co-occurring disorders. National Mental Health Association. Retrieved February 4, 2008 from www1.nmha.org/state/co-occurringTreatmentBriefing.pdf

        Olmstead, T., White, W. D., Sindlar, J. (2004) The impact of managed care on substance abuse treatment services. Health Services Research 39(2). Retrieved May 2, 2008 from http://pubmedcentral.nih.gov/articlerender.fcgi?artid=1361010

         Russell, K. (2003) An assessment of outcomes in outdoor behavioral healthcare treatment. Child & Youth Care Forum, 32(6), 355-381. Retrieved August 15, 2008 from PsycInfo database.

         Russell, K. C. (2005) Two years later: A qualitative assessment of youth well-being and the role of aftercare treatment. Child & Health Care Forum, 34(3), 209-260. Retrieved August 15, 2008 from PsycInfo database.

          Wu, p., Hoven, C. W., Okezie, N., Fuller, C., and Cohen, P. (2007) Alcohol abuse and depression in children and adolescents. Journal of Child & Adolescent Substance Abuse. 17(2) Retrieved September 23, 2008 from Http://www.haworthpress.com