The higher treated prevalence of certain medical disorders among adults with severe mental illness has three implications: substance use disorder is an important risk factor and requires early detection; integration of the treatment of medical disorders and severe mental illness should receive higher priority; and efforts should be made to develop specialized disease self-management techniques.
The new definition sets an ideal, but not unrealistic, standard for social integration in the context of psychiatric disability. High standards encourage mental health professionals and policy makers to rethink what is possible for mental health services and to raise expectations for connectedness and citizenship among persons once disabled by mental illness.
OBJECTIVES. This study examined the costs of psychiatric treatment for seriously mentally ill people with comorbid substance abuse as compared with mentally ill people not abusing substances. METHODS. Three different sources of data were used to construct client-level files to compare the patterns of care and expenditures of 16,395 psychiatrically disabled Medicaid beneficiaries with and without substance abuse: Massachusetts Medicaid paid claims; Department of Mental Health state hospital inpatient record files; and community support service client tracking files. RESULTS. Psychiatrically disabled substance abusers had psychiatric treatment costs that were almost 60% higher than those of nonabusers. Most of the cost difference was the result of more acute psychiatric inpatient treatment. CONCLUSIONS. Although the public health and financial costs of high rates of comorbidity are obvious, the solutions to these problems are not. Numerous bureaucratic and social obstacles must be overcome before programs for those with dual diagnoses can be tested for clinical effectiveness.
Quantitative and illness-centered formulations may miss much of what low-income service users with serious mental illness value in their relationships with practitioners. The opportunity to counter feelings of vulnerability and alienation with a sense of connection that is based on shared humanness may be a high priority for services for this group. Practitioner relationships that help service users feel cared about and connected to the social world address suffering in mental illness and are thus essential to the meaning of good care.
The mechanisms identified in this study facilitate operationalization of the concept of continuity of care by specifying its meaning through empirically derived indicators. Ethnography promises to be a valuable methodological tool in constructing valid and reliable measures for use in mental health services research.
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