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The Burnaby treatment center for mental health and addiction, a novel integrated treatment program for… Schütz, Christian; Linden, Isabelle A; Torchalla, Iris; Li, Kathy; Al-Desouki, Majid; Krausz, Michael Jul 30, 2013

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RESEARCH ARTICLE Open AccessThe Burnaby treatment center for mental healthand addiction, a novel integrated treatmentprogram for patients with addiction andconcurrent disorders: results from a programevaluationChristian Schütz1,2, Isabelle Aubé Linden1*, Iris Torchalla1,2, Kathy Li1, Majid Al-Desouki2 and Michael Krausz1,2,3,4AbstractBackground: Patients with addictions and concurrent disorders constitute the most underserved population in thesystem of care. There are numerous reasons why this population has so much difficulty accessing services,including behavioural issues, criminal engagement, and non-compliance with outpatient services. To improveservices to this population which is marked by multiple morbidities, high mortality and insufficient access to healthcare, the government of British Columbia, Canada developed a program for people with both substance usedisorder and one or more mental disorders who have not benefited from previous therapies.Method: In July 2008, the Burnaby Treatment Centre for Mental Health and Addiction (BCMHA), a specialized andintegrated tertiary care facility, was opened. The current article provides a description of the treatment program anda clinical profile of the population.Results: The target population is being served, at intake clients present with high rates of psychopathology,childhood and adult trauma, and substance use.Conclusion: While preliminary, these results indicate, that the novel approach of the Burnaby Centre mayconstitute a new path towards providing effective recovery for this population.Keywords: Concurrent disorders, Integrated treatment, Marginalized populationsBackgroundIndividuals with concurrent mental and substance usedisorders tend to present with multiple physical healthproblems and substantial social and behavioural prob-lems [1]. Individuals with concurrent disorders (CD) areoverrepresented in forensic settings, regularly inhabitsubstandard housing [2,3] and constitute a significantpercentage of the homeless population [4,5]. Individualssuffering from CD typically have difficulty engaging withtraditional health care services and tend to rely heavilyupon emergency care as their access point to the healthcare system [6]. The CD population exhibits extremelypoor health outcomes and has a life expectancy that isconsiderably lower than the general population [7,8].These and other concerns were recently emphasized bya group of leading American psychiatrists in a recent‘call for action’ [9].In the Canadian province of British Columbia (BC),the highest numbers of patients with CD and those withthe most severe problems are found within inner-cityneighbourhoods. In Vancouver, the area known as theDowntown Eastside (DTES) has a particularly high con-centration of CD clients and has been the focus of con-siderable efforts to develop special treatment programs,including low threshold or harm reduction approaches[10]. Although there are existing treatment programs for* Correspondence: ilinden@cheos.ubc.ca1Centre for Health Evaluation & Outcome Sciences, Providence Health CareSt. Pauls Hospital, 588-1081 Burrard St., Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© 2013 Schütz et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Schütz et al. BMC Health Services Research 2013, 13:288http://www.biomedcentral.com/1472-6963/13/288substance abuse, mental health, and physical health issues,many health care providers in the DTES have expressedconcern that these services are inaccessible to CD clients[11,12]. In longitudinal studies, having CD was associatedwith lower motivational readiness to change, lack of treat-ment engagement and attendance, and poor medicationcompliance [13,14]. Many of these individuals have ‘be-havioural issues’, such as high impulsivity, aggression, andinvolvement in criminal activity [15]. These dysfunctionalbehaviours may be an expression of street entrenched life,mental disorders, substance intoxication/dependence, or acombination of all of these dimensions. Unfortunately,these types of behaviours will often disqualify CD clientsfrom health services, and bring individuals into frequentcontact with the criminal justice system [16]. Resourcescould be more effectively allocated if these concurrentconditions were treated consistently and if the availabletherapies were better tailored to the realities of thisvulnerable population [17].Development of a treatment model for individuals withCD in British ColumbiaDespite an influx of resources into this vulnerable neigh-bourhood over the past 20 years, the health concernsfacing DTES residents and clients with CD throughoutthe province of BC have not been resolved. Therefore, in2008, an overall consensus for significant change drovethe creation of a new approach to managing the healthissues of CD clients. The development of a specializedprogram for clients with CD was mandated by the pro-vincial government of BC. In April 2008, funding forthe development of a specialized, 100 bed provincialtreatment facility was announced, and in July of 2008,the Burnaby Treatment Centre for Mental Health andAddiction (BCMHA) was opened. The founding principlesof BCMHA were developed by a panel of experts withranging specialties from substance abuse treatment,psychological therapy and rehabilitation as well as repre-sentatives from acute care, community care, and forensicservices. The model of care was designed to incorporateprinciples of strength-based care and the concepts ofassertive treatment, motivation-based treatment, time-unlimited treatment, comprehensive programming, treat-ment approaches tailored to the receptiveness of clients(e.g. starting at low intensity), harm reduction leading toabstinence, stepped care, and cultural competence and sen-sitivity [18]. The BCMHA emphasizes two key strategies: 1)the management of relapse and crisis as the basis of achiev-ing recovery for patients, and 2) long-term rehabilitation-focused care, reflecting a core belief that while recovery is along process-it is the only alternative to reduce the seriousmortality in this population.The BCMHA was deemed to be a tertiary care pro-gram and given the mandate to provide comprehensivecare to individuals with CD who present with severemental health, physical health, substance use, and be-havioural issues. Comprehensive care was defined asincluding all stages of treatment for each dimension ofcare, including withdrawal management, psychiatric care(excluding emergency care), psychosocial care, and medicalcare (excluding emergency/acute care).The treatment program is designed for clients to stayup to 9 months at the inpatient facility/treatment program;thus reflecting the extensive change required duringrecovery from concurrent disorders. Although clientsare encouraged to stay 9 months, there is considerableflexibility, as some clients will require shorter involvementwhile others will benefit from long-term care, therefore thecenter does not have strict and arbitrary time limits. Thetreatment team consists of care providers including psychi-atrists, psychologists, physicians, nurses, counsellors, healthcare workers, social workers, in addition to occupationaltherapists, art and music therapists, and providers ofalternative medicine. Treatment goals are determinedin team meetings with the client. Treatment is basedon best evidence as provided by international treatmentguidelines and reviews of treatment efficacy. Treatmentincludes individual and group interventions targetingspecific issues such as relapse prevention, contingencymanagement, anger management, and motivationalinterviewing. Interventions are offered at different levelsof complexities, allowing an individual to progress fromsimpler, low intensity approaches to more demandingand intensive interventions. Table 1 describes the differenttreatment components available to clients at BCMHA.Concurrently, clients receive medication treatment formental health and medical issues. Clients are encouragedto progress from tightly supervised medical treatment to aweekly handout of medication.The Provincial Health Services Authority (PHSA), whoestablished access protocols under which the five regionalhealth authorities in British Columbia could refer CD cli-ents to the BCMHA, organizes the referral process for theBCMHA. According to the access protocol, the patientsmust have failed other programs on a regional level andmust have significant issues in each of the four identifieddomains: mental health, substance use, physical healthand behavioural. Furthermore, clients eligible for ad-mission must have been unable to adequately engagewith, receive services from, or benefit from traditionalmental health and addiction programs.The centre’s mandate was to meet the needs of thevulnerable population in BC, and to help a populationwhose complexity of daily living made it difficult for themto benefit from existing services. As clients at the BCMHAare both difficult to engage in treatment and present withextremely challenging combinations of health problems,the present study’s objective is to describe the needs ofSchütz et al. BMC Health Services Research 2013, 13:288 Page 2 of 8http://www.biomedcentral.com/1472-6963/13/288these patients by presenting baseline (intake) data tooutline the level of mental illness in this populationand to inform planning and tailoring of treatment ser-vices for these difficult to treat clients. A description ofthe characteristics of the client population and theirinitial responses to the intervention are presented.MethodsThis program evaluation consisted of a baseline assess-ment, and a follow up assessment at 6 months. Baselinedata were collected from June 2009 to January 2010, andfollow up assessment began in December 2009 and werecompleted in March 2010. All potential participants inthe study were adult residents of the BCMHA who hadbeen admitted in accordance with a standardized accessprocess that was regulated by the BC Provincial HealthServices Authority [19]. One hundred and twenty-eightclients who were consecutively admitted to the BCMHAwere contacted to take part in an assessment, andassessed for eligibility by the intake team. We completedthe baseline assessment for the pre-test within 6 weeksof intake. Clients were asked to respond in their baselineassessment regarding their status at intake. A total of112 clients consented to participate in the study and 92participants completed the minimal baseline assessment.Baseline information included information on mentaldisorders, substance use patterns, and health status. Dueto funding restrictions that prevented tracking of pa-tients who were discharged or had dropped out of thestudy, follow-up interviews were completed only of indi-viduals who were still at the treatment centre. This studywas reviewed and approved by the University of BritishColumbia Research Ethics Board.We collected demographic information, which includedage, gender, ethnicity, education, recent employment, andhousing situation.Mini-International Neuropsychiatric Interview (MINI)Plus [20] is a structured clinical interview to assess currentand lifetime substance use and mental disorders accordingto the criteria of the Diagnostic and Statistical Manual, 4thedition (DSM-IV).Childhood Trauma Questionnaire, short form (CTQ-SF)[21] is a retrospective self-report inventory that assesseddifferent types of childhood maltreatment on five subscales:Physical Abuse, Emotional Abuse, Sexual Abuse, PhysicalNeglect, and Emotional Neglect. The questionnaire consistsof 28 items answered on a 5-point Likert scale, includingthree items to assess minimization/denial. We adopted theseverity classification proposed by the developers.Trauma History Questionnaire (THQ) [22] is a 24-itemself-report measure that examines experiences withpotentially traumatic events, including crime-relatedTable 1 BCMHA recovery and clinical pathway modelTreatment Goals Treatment elementsRecovery 1(20–40 days)• Complete the withdrawal management process • Medication treatment by psychiatrists and GPs.One-to-one sessions with psychiatrists and counsellors.• Stabilize all medical and psychiatric disorders• Stabilize sleep patterns • Complimentary therapies e.g.• Reduce behavioural and emotional instability • acupuncture and yoga.• Group programs include: Motivational Enhancement,Anger Management, Early Recovery - Substances (Matrix),Early Recovery - Mental Health, Emotional Boot Camp(introductory), Life Skills, Talking Circle.• Introduce a range of healthy habits• Prepare residents to participate in structured educational,therapeutic, and recreational activities• Recreational activitiesRecovery 2(90–180 days)• Provide clients with a basic understanding of the nature ofaddiction and mental health problems• Continued medical follow-up, therapy sessionsand complimentary therapies.• Teach clients techniques for self- managing emotions and behaviours • Group programs include: Emotional Bootcamp, AngerManagement, Seeking Safety, Cognitive BehaviouralTherapy (for psychosis and affective disorders), EmotionalBoot Camp, Mindfulness, Relapse Prevention (Matrix),Living Free, Life Skills, Talking Circle, Stages of Change,• Allow clients to explore a range of creative and recreational activities• Introduce clients to techniques for managing substanceuse and mental health problems• Work on developing a personal strengths inventory • Hep C treatment group.• Recreational activities and Art therapyRecovery 3(40–60 days)• Identify a secure housing situation • Continuation of Recovery 2 programs as well asLife Management, Stepping Up and Stepping Out.• Establish a financial and vocational plan• Connecting the client with community organizations and resources,including connecting clients with the Ministry of Housing andIncome Assistance (former MIEA) and other providers• Community activity and involvement is supported.• Self-medication plans initiated.• Developing and implementing a relapse prevention plan, includingconnections with treatment providers in the community as appropriateSchütz et al. BMC Health Services Research 2013, 13:288 Page 3 of 8http://www.biomedcentral.com/1472-6963/13/288events (e.g., robbery, burglary), general disasters (e.g.,accidents, natural or man-made disasters, war, injury,life-threatening illnesses, or deaths of others), and sexualand physical assault. For each item, the clients were askedto indicate the frequency and at what age they had experi-enced the event.The Brief Symptom Inventory (BSI) [23] is a 53 itemself-report questionnaire that measures nine dimensionsof psychological distress over the past 7 days using a five-point Likert scale. The nine dimensions are: Somatization,Obsession-Compulsion, Interpersonal Sensitivity, Depres-sion, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideationand Psychoticism. In addition to the average score for eachindividual dimension, we calculated the Global SeverityIndex (the average score of all items combined) as ameasure of overall current distress.The Maudsley Addiction Profile (MAP) [24] is a self-report measurement that assesses current substanceuse related problem behaviours. Participants were asked toindicate the frequency, amount, and route of adminis-tration of alcohol, cocaine (powder or crack cocaine),cannabis, opioids (heroin, nonprescribed methadone,or nonprescribed opioids), amphetamines (amphetaminesor crystal methamphetamines), and nonprescribed benzodi-azepines they used in the past 30 days.Descriptive analyses were used to describe the sample,including numbers and percentages for dichotomizedsociodemographic and clinical variables, and means andstandard deviations (SD) for continuous variables. Com-parison between baseline and follow-up MAP and BSImeasures were assessed as indicators of the client’s pro-gress in treatment. Within this matched analysis, pairedt-test and chi-square test were employed to examine themean differences and the differences in proportions. Allreported p-values are two-tailed and significance was setat p ≤ 05. Analysis was performed using SAS version 9.1(SAS Institute, Inc, Cary, North Carolina).ResultsNinety-two participants completed the baseline assessment.The mean age at baseline was 40.2 years, and 21.7% identi-fied as Aboriginal. Complete client demographic character-istics can be found in Table 2. The average length of stay atBCHMA for all clients discharged in 2010 was 4.8 months.On the BSI, clients at intake scored highest in dimensionsof obsession-compulsion (2.11) and depression (2.08).However, symptoms for all dimensions on the BSI werehigh. Full scores for the BSI can be found in Table 3.Extremely high rates of trauma were found in thispopulation using the CTQ and the THQ. More than halfof the sample had experiences at least one form oftrauma in their childhood; the most frequently reportedexperience was emotional abuse. On the THQ, generaldisasters and crime related events were most frequentlyreported. The full results for trauma histories are presentedin Table 4.Results from the MAP revealed high rates of substanceuse, with crack or powder cocaine use the most commonsubstance used at 65.2%. The complete list of substancesused is found in Table 5.The MINI revealed that for lifetime mental disorders,major depressive episodes was the most frequently reportedTable 2 Client’s demographic characteristicsVariables N = 92 (%)Mean Age (SD) 40.2 (10.3)(Range) (21–63)GenderMale 60 (65.2%)Female 32 (34.8%)EthnicityWhite 64 (69.6%)Aboriginal 20 (21.7%)Other 8 (8.7%)Education≥ high school exam 27 (29.3%)< high school exam 65 (70.7%)Recent EmploymentNo 81 (88.0%)Yes 11 (12.0%)Housing StatusFixed Address 29 (31.5%)SRO* 12 (13.1%)Shelters/Surfing 22 (23.9%)Living on the street/homeless 29 (31.5%)*SRO: Single Room Occupancy (generally substandard housing).Table 3 BSI dimensions scores and composite GSI score, andcomparison of baseline and follow-up (FU) data for n = 47BSI Dimension Baseline,all clients(N = 92)Baseline ofthose assessedat FU (n = 47)Follow up(n = 47)pMean (SD) Mean (SD) Mean (SD)Somatization 1.43 (1.02) 1.69 (1.04) 1.14 (0.84) .006Obsess.-Compuls. 2.11 (1.05) 2.29 (1.11) 1.67 (1.09) .0004Interp. Sensitivity 1.92 (1.20) 2.07 (1.22) 1.50 (1.14) .0014Depression 2.08 (1.16) 2.21 (1.17) 1.40 (1.06) <.0001Anxiety 1.90 (1.13) 2.11 (1.20) 1.40 (1.08) <.0001Hostility 1.48 (1.05) 1.59 (1.09) 1.19 (1.02) .0258Phobic Anxiety 1.44 (1.15) 1.66 (1.24) 0.97 (0.99) <.0001Paranoid Ideation 1.77 (1.06) 1.96 (1.10) 1.52 (0.94) .0024Psychoticism 1.77 (0.96) 1.83 (0.99) 1.29 (0.99) .0004GSI 1.78 (0.91) 1.94 (0.95) 1.31 (0.83) <.0001Schütz et al. BMC Health Services Research 2013, 13:288 Page 4 of 8http://www.biomedcentral.com/1472-6963/13/288diagnosis (64.8%). For substance use disorders, drugdependence (78.4%) was more frequently reported thanalcohol dependence (65.9%). The complete list of lifetimeprevalence rates of mental and substance use disorderscan be found in Table 6.A total of 47 clients (51%) completed the follow-upassessment after six months. There was a significantreduction in psychopathology symptoms from intaketo 6 months across all BSI dimensions. The means and SDsof the baseline and the follow-up BSI scores can be foundin Table 3, along with the p-values for the comparisons.Specifically, participants improved in dimensions ofsomatization (t(46) = 4.489, p = .006), obsessive-compulsive(t(46) = 3.900, p = .0004), interpersonal sensitivity (t(46) =3.428, p = .0014), depression (t(46) = 5.239, p < .0001),anxiety (t(46) = 4.507, p = <.0001), hostility (t(46) = 2.304,p = .0258), phobic anxiety (t(46) = 4.778, p < .0001), paranoidideation (t(46) = 3.209, p = .0024), psychoticism (t(46) =3.739, p = .0004), and the GSI (t(46) = 5.204, p < .0001).Even after using a Bonferroni correction to account formultiple testing (resulting in an alpha of .005), the differ-ences from baseline to follow-up remained significant onall dimensions except somatisation and hostility.Results from the MAP indicated reduction of substanceuse to overall minimal use. The numbers and percentagesof substance use at baseline versus follow-up are presentedin Table 5. Specifically, the rates decreased significantlyfor alcohol (χ2(1) = 7.42, p = .006), heroin (χ2(1) = 4.97,p = .026), and cocaine (χ2(1) = 19.3, p < .0001). Using aBonferroni correction resulted in an alpha of .0083, indi-cating that the changes remained significant for alcoholand cocaine use. The differences from baseline to follow-up were not significant for illicit methadone (χ2(1) = 1.90,p = .168), benzodiazepines (χ2(1) = 1.79, p = .181), andamphetamines (χ2(1) = 1.79, p = .181).DiscussionThe present study focused on describing a residentialtreatment program designed to address the needs of in-dividuals with chronic and severe concurrent conditions.The data from the baseline assessments clearly presentsthat this population was suffering from severe concurrentdisorders at the time of intake to the clinic. Compared tonormative data provided by the authors of the BSI, thepsychopathology distress not only exceeded the psy-chopathology of the general population, but also thepsychopathology found among psychiatric inpatients [23].The high levels of mental illness, concurrent disorders,and multiple traumatic experiences present in this popula-tion clearly demonstrate the importance of comprehensiveand integrated care to achieve sustainable recovery.Table 4 Results of the Childhood Trauma Questionnaire(CTQ, n = 75) and the Trauma History Questionnaire(THQ, n = 84)CTQ subscales n (%)Emotional Abuseno to low 24 (32.0%)moderate to severe 51 (68.0%)Physical Abuseno to low 26 (34.7%)moderate to severe 49 (65.3%)Sexual Abuseno to low 33 (44.0%)moderate to severe 42 (56.0%)Emotional Neglectno to low 32 (42.7%)moderate to severe 43 (57.3%)Physical Neglectno to low 32 (42.7%)moderate to severe 43 (57.3%)Trauma History Questionnaire n (%)Physical Assault (yes) 55 (65.5%)Sexual Assault (yes) 37 (44.0%)Crime–related events (yes) 65 (77.4%)General Disaster (yes) 69 (82.1%)Table 5 Prevalence of substance use at baseline for all clients, and comparisons of baseline and follow-up substance use forindividuals available for follow up (n = 47)Substances Baseline, all clientsN = 92Baseline of those assessedat FU n = 47 (%)Follow-upn = 47 (%)pAlcohol 45 (48.9%) 16 (34.0%) 5 (10.6%) .006Heroin 31 (33.7%) 15 (31.9%) 6 (12.8%) .026Crack or powder cocaine 60 (65.2%) 30 (63.8%) 9 (19.1%) <.0001Illicit methadone 5 (5.4%) 4 (8.5%) 1 (2.1%) .168Illicit benzodiazepines 14 (15.2%) 7 (14.9%) 3 (6.4%) .181Amphetamine 12 (13.0%) 7 (14.9%) 3 (6.4%) .181Injection Drug Use 32 (34.8%) - -Sharing syringes 2 (2.2%) - -Schütz et al. BMC Health Services Research 2013, 13:288 Page 5 of 8http://www.biomedcentral.com/1472-6963/13/288Health care systems traditionally focus on mental healthand addiction separately based on different philosophiesof care. While many mental health services are increasingtheir treatment to include individuals with “mild to moder-ate” forms of substance dependence, and addiction servicesare increasing their treatment to include individuals withmild to moderate mental disorders, it is the individual withcomplex, severe, and concurrent conditions, that is stillcaught in the gap left between two incomplete and oftenincompatible treatment models [1,17]. However, increas-ingly are integrated treatment approaches of concurrentsubstance use and mental disorders accepted to be themost promising and best practice strategy [25].Reflecting on the presented health issues in this sample,it is important to note the severity of problems present, andyet the limited access to care. This sample displayed majormental illness, trauma, and substance use, and althougheach of these issues requires medical attention, the clients’access to care prior to involvement with BCMHA wasextremely limited. The high level of traumatic experiencesfrom early childhood to adulthood presents a chroniccondition that needs more attention both as a contributingfactor to mental disorder and substance use order and as apotential roadblock to accessing services. Integrated treat-ment approaches that address both trauma/PTSD and sub-stance use have shown some initial promising results butneed to be further refined and evaluated [26]. Recovery andreintegration into society is only possible with a compre-hensive and integrated long-term concept, including hous-ing and social support. Stimulant use in this population ishigh as they are low in cost and broadly available, resultingin chronic substance use patterns that include a rangeof psychotropic substances and routine polysubstanceuse. Therefore, treatment must address polysubstanceuse, rather than dependence to one substance in particular.As a result of the referral process, it is expected thatthese clients represent the most complex populations inmental health and addiction care in BC. BC’s populationis concentrated with about 60% in the metropolitan areaof Vancouver and the lower mainland. It seems that accessis more limited from some areas, such as very rural areascompared to cities and the metropolitan area of Vancouver.This was not specifically assessed, but may constitute anarea of interest for further follow up.The manner in which the BCMHA program under-stands and responds to relapse is central to the program.Relapse is a regular occurrence in substance use and CDclients, and was often the reason that BCMHA clientshad been discharged from other programs or from housingfacilities. Discharge often resulted in these clients living onthe street despite their severe mental, addictive, andphysical illnesses. From our experience with BCMHAwe have learned that a comprehensive program can be usedto achieve significant gains, as shown by the improvementin psychopathological symptoms and decreased substanceuse even before clients achieved abstinence or before men-tal health problems are fully resolved. These data suggestthat it is possible to provide effective integrated care forpatients who have not achieved full abstinence and who re-quire longer-term care before being able to stay abstinent,as demonstrated by an average length of stay of 4.8 months,as compared to many 12-week programs.LimitationsOur study has some methodological limitations thatwarrant discussion. Two important domains were notaddressed sufficiently given the major health concernsin this population. First, the level of cognitive functioningand all related conditions, due to mild traumatic braininjury, and fetal alcohol spectrum disorder, etc. Second,the presence of possible Axis II personality and develop-mental disorders. The assessment of both domains istime consuming and needs highly trained interviewers.These areas need to be the focus of future studies. Thehigh rates of chronic substance use behaviours and disor-ders raise concerns about the interference of substance usesymptoms (e.g., intoxication or withdrawal) with properpsychiatric assessment. Although the reported mentaldisorder symptoms and diagnoses are based on stan-dardized assessments, over- or underestimation cannotbe excluded, given the level of our patient’s impairmentand the complexity of concurrent conditions. Further-more, participant’s information on both baseline andfollow-up substance use behaviours was derived viaself-reports without any biochemical validation, and thusmay be affected by reporting bias. Similarly, self-reportedinformation on trauma histories in childhood and adult-hood was not confirmed by external sources and may beover- or underestimated in our study.A major limitation of the follow-up results is the factthat they were based on the minority of patients whoTable 6 Patient’s lifetime prevalence rates of DSM-IVbased mental and substance use disorder diagnosesDiagnoses N = 88 (%)Major depressive episode 57 (64.8%)Manic(Hypo-manic) episode 36 (40.9%)Dysthymia 2 (2.3%)Psychotic episode not induced by substances 49 (55.7%)Panic disorder 30 (34.1%)Agoraphobia 43 (48.9%)Posttraumatic stress disorder 38 (43.2%)Antisocial-personality disorder 32 (36.4%)Alcohol dependence 58 (65.9%)Drug dependence 69 (78.4%)History of suicide attempt(s) 52 (59.1%)Schütz et al. BMC Health Services Research 2013, 13:288 Page 6 of 8http://www.biomedcentral.com/1472-6963/13/288were still present in the facility at six months. Not onlydoes this attrition result in low statistical power, but it isalso very likely that these individuals are not representa-tive of all patients accessing the BCMHA. As such, ourfollow-up results need to be regarded as preliminary andsuggestive, and have to be confirmed with more systematicdata collection that assesses mental health and substanceuse outcomes over a longer follow-up time period using anintention-to-treat approach. Finally, lack of a control condi-tion, treatment attendance and compliance measures forpatients, and treatment fidelity or manual adherencemeasures for staff limits conclusions regarding the actualimpact of the specific psychiatric intervention. However, wehope that this initial data will provide incentive for a morecomprehensive analysis of the situation of individuals withcomplex concurrent disorders.ConclusionsAs indicated earlier, the eligibility criteria for the BCMHAincludes demonstrated failure in other treatment programs;BCMHA serves as a “last resort” tertiary care facility. Thereare no comparable, specialized programs in Canada focus-sing on these high need clients [27], which makes theBCMHA particularly interesting and challenging from botha system and a research perspective. With an interdisciplin-ary approach, it is possible to retain and support clientswith the highest complexity of mental and substance disor-ders into treatment and achieve significant improvements.The current study does not seek to identify the roadblocksto accessing care, however, this is an important feature thatneeds to be further investigated into, as appropriate healthcare delivery is only achieved if and once appropriateservices are accessed.Many of the patients who participated in this studywere never appropriately assessed before admission toBCMHA. Although a high prevalence of traumatic expe-riences or impairments in the cognitive functioning wereknown about these clients, no neuropsychological tests,brain imaging, or standardized psychometric tests inthose fields were documented in the files or mentionedby them. Without standardized assessment or systematicoutcome control it is hard to develop an appropriatecare plan and provide the necessary supports. The needfor better multi-dimensional assessment is a core pre-requisite of any professional care for this population inthe future. The consequences of all these poor healthoutcomes are devastating for this high need and highrisk population, their families, their peers, and especiallytheir children. The lack of appropriate capacity andquality of care needs to be addressed as a health crisis.For individuals with the highest morbidity, access andquality of care need to be improved. The approachoffered by the BCMHA may constitute a decisive steptowards this direction.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsCS: Co-PI, conceptualizing the study, writing protocol, supervising analysis,conceptualizing and writing the manuscript, and editing. IL: organizing theassessments, conducting literature review, interpretation and discussion ofresults, writing and editing of the manuscript. IT: supervising datamanagement, training interviewer, conducting literature review,interpretation and discussion of results, writing and editing of themanuscript. KL: data management, statistical analysis of the data. MA:developed Table 1, and editing of the manuscript. MK: PI of the evaluationstudy, writing protocol, editing the manuscript. All authors read andapproved the final manuscript.AcknowledgementsFinancial support for this survey was received from the Provincial HealthServices Authority (PHSA).Author details1Centre for Health Evaluation & Outcome Sciences, Providence Health CareSt. Pauls Hospital, 588-1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada.2Department of Psychiatry, University of British Columbia, 430-5950 UniversityBoulevard, David Strangway Building, Vancouver, BC V6T-1Z3, Canada.3Vancouver Coastal Health, 601 West Broadway, Vancouver, BC V5Z 4C2,Canada. 4School of Population and Public Health, University of BritishColumbia, 5804 Fairview Avenue, James Mather Building, Vancouver, BC V6T1Z3, Canada.Received: 2 October 2012 Accepted: 25 July 2013Published: 30 July 2013References1. Mueser KT, Noordsy DL, Drake RE, Fox L: Integrated treatment for dualdiagnosis. New York, NY: Guilford Press; 2003.2. Buckley PF: Prevalence and consequences of the dual diagnosis ofsubstance abuse and severe mental illness. 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BMC Health Services Research 2013 13:288.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSchütz et al. BMC Health Services Research 2013, 13:288 Page 8 of 8http://www.biomedcentral.com/1472-6963/13/288


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