Results of the Survey of Mental Health and Addictions Agencies in Ontario for Concurrent Disorders Screening and Assessment tools
Cindy Smythe
Beth Powell
Leona Murphy
Roseanne Pulford
Centre for Addiction and Mental Health
October 2003
Survey of Mental Health and Addictions Agencies in Ontario for Concurrent Disorders Screening and Assessment tools
Background
In 2001, Health Canada released its Best Practices document, Concurrent Mental Health and Substance Use Disorders as part of Canada’s drug strategy. Concurrent disorders are defined as the co-occurrence of mental health and substance use disorders. The document provides an updated synthesis of research information and offers recommendations for screening, assessment and treatment/support of this population based on research information available.
The importance of screening is emphasized in the document when the authors state: “Attempts to treat substance abuse among people with mental health disorders, and vice versa, must begin with recognition. The purpose of screening is not to determine the complete profile of psychosocial functioning and needs, or to make a diagnosis; but rather to identify whether the individual may have a mental health or substance abuse problem that warrants more comprehensive assessment.” (p.28). “Assessment is seen as intimately linked to treatment planning and the delivery of quality service Assessment data also serve another important function as baseline information for the determination of outcome.“ (p.40)
Currently, the Communications, Education and Community Health (CECH) department at the Centre for Addiction and Mental Health (CAMH) supports three priority program areas. One priority area, addressed in this project, is Concurrent Disorders. The Strategic Goal for the Concurrent Disorders priority area is to “improve the capacity of the Mental Health and Addiction systems and the ability of service providers in Ontario to meet the needs of people affected by concurrent disorders.” (Concurrent Disorders Plan, 2003, p. 7).
The Concurrent Disorders priority area has three strategic objectives. The objective related to this project is to help providers recognize the use of substances and the existence of mental disorders so that they can be more successful in their support of the client. The anticipated outcome is to increase the capacity of mental health and addictions service providers to identify those living with concurrent disorders through use of recommended screening and assessment tools (Concurrent Disorders Plan, p. 8).
Finally, in 1995-96, the Addiction Research Foundation conducted a survey of the then 700 addiction and mental health service provider organizations in Ontario in order to find out the state of service provision to clients with concurrent disorders (Melinyshyn et al., 1996). We were interested to see what changes had occurred in the seven years between surveys.
Our Project
In order to discover the current practice in screening and assessment of clients living with concurrent disorders in Ontario, surveys were sent to all Ministry of Health and Long Term Care (MOHLTC) funded addiction and mental health agencies. Through our survey, we hoped to answer the following questions:
· are clients in mental health agencies being screened and assessed for substance use disorders?
· are clients in addiction agencies being screened and assessed for mental health disorders?
· which screening and assessment instruments/methods are agencies using?
· are agencies referring to outside agencies for assessment purposes?
For purposes of the survey, screening was defined for agencies as:
· a brief process that collects information in only enough detail to determine the client’s immediate needs and provide direction for next steps.
Assessment was defined as:
· an investigation that provides the clinician with detailed and comprehensive information to help determine the nature and severity of the problem.
Method
All MOHLTC funded addiction and mental health agencies were sent surveys specific to their sector, i.e., all mental health agencies were asked about screening and assessment for substance use disorders; all addiction agencies were asked about screening and assessment for mental health disorders. French versions of the surveys were sent to Francophone agencies. Please see Appendix 1 for copies of surveys.
Mailing labels for addictions agencies were obtained from the Drug and Alcohol Registry of Treatment (DART). Mental Health agency labels were received from the Ministry of Health and Long Term Care.
The surveys were mailed in early March 2003 with a request to fax back the completed survey within two weeks of receipt. Agencies that had not returned their completed surveys within three weeks of the mailing were sent a reminder postcard and a second copy of the survey if requested.
Results
Response rates and distribution of responses by location
Two hundred and thirteen surveys were mailed to addiction agencies and 121 completed surveys returned for a 57% response rate. Surveys were mailed to 342 mental health agencies and 168 responses were received for a 49% return rate.
Table 1 below shows the distribution of responses by location across the province for each sector.
Table 1
Agency location by 1st letter of postal code
Addictions (121 surveys returned)
Mental Health (168 surveys returned)
Count
%
Count
%
K (Eastern Ontario)
22
18.2
28
16.7
L (Southwestern Ontario)
23
19.0
24
14.3
M (Toronto & area)
19
15.7
38
22.6
N (Southwestern Ontario)
23
19.0
44
26.2
P (Northeastern & Northwestern Ontario)
34
28.1
34
20.2
Common Questions
Table 2 below shows responses from the four questions common to both sectors. As can be seen, the responses are similar in both sectors although addictions agencies tend to assess for mental disorders somewhat more than mental health agencies assess for substance use disorders.
Table 2
Questions common to both the addiction and mental health sectors
Addictions
% answering yes
Mental Health % answering yes
Do you screen for substance use disorders/mental health disorders?
82.6 %
82.1 %
If yes, do you ask a few questions?
76 %
78.6 %
Do you assess for substance use disorders/mental health disorders?
41.3 %
32.1 %
Do you refer out?
71.1 %
70.8 %
The remaining survey questions referring to instruments/methods used in screening and assessment were specific to the sector and will therefore be presented separately. For responses to all open ended questions, please see Appendix 2.
Ad
dictions Agencies – Screening Questions
Addictions agencies were asked about specific instruments/methods used for screening clients for mental health disorders. Table 3 below shows the number of agencies reporting screening and Table 4 shows the number using the instruments/methods listed on the survey. Agencies could check more than one instrument/method and also could write in other instruments not listed.
Table 3
Do you currently screen for mental health disorders?
No.
%
Yes
100
82.6
No
21
17.4
Table 4
Screening Instrument/Method for mental disorders
No.
%
Ask a few questions
92
76.0
GHQ/GHQ-28
20
16.5
ASI
4
3.3
Concurrent Disorder Screening Test
2
1.7
Other(s)
39
32.2
In List 1 (Appendix 2) are other screening instruments and methods used. The most common other instruments used were the BASIS-32, part of the standardized assessment tools for addictions, (mentioned by 11 respondents) and the Beck Depression Inventory (mentioned by 3 respondents). Also, agencies used other mental health-related questions taken from the standardized assessment tools.
Many agencies stated they reviewed previous client records, particularly agencies that were part of hospital-based programs and had access to prior admission histories. Information about mental health issues was also provided by referral sources. Other agencies asked detailed intake questions that inquired about mental health problems.
Addictions Agencies – Assessment Questions
Addictions agencies were then asked about specific instruments/methods used for assessing clients for mental health disorders. Table 5 below shows the number of agencies reporting assessing and Table 6 shows the number using the instruments/methods listed on the survey. Agencies could check more than one instrument/method and also could write in other instruments not listed.
Table 5
Do you currently assess for mental health disorders?
No.
%
Yes
50
41.3
No
71
58.7
Table 6
Assessment Instrument/Methods for mental health disorders
No.
%
Global Assessment of Functioning
15
12.4
Structured Clinical Interview for Axis I DSM IV Disorders
11
9.1
Psychiatric Interview
27
22.3
Other(s)
34
28.1
In List 2 (Appendix 2) are other assessment instruments and methods used. Again addiction agencies refer to the BASIS 32 (mentioned by 7 people) and the Beck (mentioned by 5 people). Also, agencies used other mental health-related questions taken from the provincial assessment tools for addictions. Again, agencies in hospital-based programs use in-house staff for assessments; previous mental health assessments also provide some assessment information.
In List 3 (Appendix 2) is a list of where addictions agencies refer clients for mental disorders assessments. The referral is most often to a combination of community health agencies, like CMHA, and physicians. Some agencies report long waits for mental health assessment as a barrier, particularly for psychiatric assessment and diagnosis. Urgent consults are sent to a crisis service. One agency uses the model of an on-site paid consultant psychiatrist who then follows the treatment of the concurrent disordered client in the agency. Another agency reports using a shared care model, referring to the family doctor who will share the care with a consulting psychiatrist.
Mental Health Agencies – Screening Questions
Mental health agencies were asked about specific instruments/methods used for screening clients for substance use disorders. Table 7 below shows the number of agencies reporting screening and Table 8 shows the number using the instruments/methods listed on the survey. Agencies could check more than one instrument/method and also could write in other instruments not listed.
Table 7
Do you currently screen for substance use disorders?
No.
%
Yes
138
82.1
No
30
17.9
Table 8
Screening Instrument/Method for substance use disorders
No.
%
Ask a few questions
132
78.6
Quantity/Frequency
78
46.4
CAGE or CAGE/AID
24
14.3
Dartmouth Assessment of Lifestyle Instrument
3
1.8
Michigan Alcoholism Screening Test
12
7.1
Drug Abuse Screening Test
13
7.7
Alcohol Use Disorders Identification Test
5
3.0
Concurrent Disorder Screening Test
2
1.2
Other(s)
23
13.7
In List 4 (Appendix 2) are other screening instruments and methods used. Many agencies report referrals to the addictions sector to have the standardized tools from the addictions sector administered for screening and assessment.
Mental health agencies were then asked about specific instruments/methods used for assessing clients for substance use disorders. Table 9 below shows the number of agencies reporting assessment and Table 10 shows the number using the instruments/methods listed on the survey. Agencies could check more than one instrument/method and also could write in other instruments not listed.
Table 9
Do you currently assess for substance abuse disorders?
No.
%
Yes
54
32.1
No
114
67.9
Table 10
Assessment Instrument/Method for substance use disorders
No.
%
Alcohol Dependence Scale
12
7.1
Short Alcohol Dependence Scale
9
5.4
SASSI
6
3.6
Measure of Stage of Change
23
13.7
Other(s)
39
23.2
In List 5 (Appendix 2) are other assessment instruments and methods used. Again many agencies report referrals to the addictions sector to have the standardized tools administered.
In List 6 (Appendix 2) is a list of where mental health agencies refer clients for substance abuse disorders assessments. As stated above, many mental health agencies use the addictions sector for substance abuse screening, assessment and referrals.
Finally, respondents were asked for any comments or suggestions they might have about screening/assessment of clients with concurrent disorders. For addiction agencies (please see List 7, Appendix 2), the most frequent comment was concerning tools or instruments. For example, some people felt that the available instruments are too generalized “MOHTLC mandated tools for addiction assessment only screen through use of BASIS-32; clients have a great deal of difficulty completing this tool, and the results are far too generalized to be very helpful to the clinician. Another person requested “any screen developed should have some ability to address severity. Our agency has the ability to work with mild to moderate mental health concerns, but not serious or severe.” There was concern expressed that tools be brief and easy to use, be standardized across all agencies and be validated., “resulting screening tools should be very brief (given the growing number of issues being screened) followed by short standardized tools for detailed assessment”.
The next concern was that special populations, e.g., youth, women, elderly, immigrants not be ignored when developing tools, “There is a lack of clarity and consensus in the field regarding what constitutes a concurrent disorder in youth. We lack specific assessment tools”. Another respondent stated there should be “sensitivity to women’s issues, particularly as they pertain to substance and trauma”.
Training issues emerged next in frequency, “I feel as alcohol and drug workers we should get training plus certification in assessing concurrent disorders” and “whatever is developed for general use needs to be supported by appropriate training”.
The next issue was wait lists and access to mental health professionals. These concerns address the whole mental health continuum of care. For example, they ask for “assist[ance] with access to psychiatrists able to provide assessments for community based programs”. Another respondent observed “obtaining a mental health assessment for our clients is often difficult, with a lack of providers and very long wait lists. Once they are assessed, it’s then difficult to find any continuing care. Ongoing assessment or re-assessment is extremely difficult, especially in cases where substance use may have affected the initial diagnosis and we are seeking an updated assessment (it is not unusual for our clients to come with one label and then have another mental health professional question that label and assign another)”.
In List 8 (Appendix 2) are comments and suggestions from mental health workers. Again, tools and instruments were most frequently mentioned. Mental health workers did not seem to be aware of available screening instruments for their own use, “information regarding best practice screening tools or instruments would be helpful” and “we are interested in the tools mentioned in question 1 and can these tools be adapted to be useful to a crisis mental health team?”
Next most frequent comment was about training and was often simply stated, “any training would be appreciated”. Next were issues about coordination of mental health and addiction services. For example, “although we are able to recognize mental health issues through screening and assessment, we are currently making assumptions about the level and use of substances by individuals we see. Better partnership need to be formed.”
Mental health workers were also concerned about special populations, “why haven’t you listed any tools specific to the seniors population?”, “we need culturally appropriate tools that we can use, in addition to tools that can be translated into Aboriginal languages, also tools must be sensitive to gender and sexual orientation issues”.
Finally, “this [identification of tools] is the easy part, the problem is lack of services for people with concurrent disorders, e.g., psychiatric care, treatment programs, case management”.
Conclusions
Both sectors are aware of the issue of concurrent disorders in their clients. This is reflected in their screening, assessment and referral practices. Also, agencies seem to be aware of the differences between screening and assessment in that they report screening about 80% of the time and assessing only half of that. For assessment purposes, each sector needs the other. Even though both sectors refer out for assessment equally, it seems that mental health agencies nearly always refer to provincial addiction agencies while addiction workers refer to a variety of mental health service providers. This list spans the continuum of care including community agencies, family physicians, psychiatrists, psychologists, hospital emergency departments, ACT teams, and crisis centers. This might reflect the fact that the addictions sector has a system of assessment and referral services and standardized assessment tools of which mental health workers are aware. On the other hand, comments from the addictions sector seem to reflect a less standard approach to referring into the mental health sector.
Data from this survey reinforces the anticipated outcome of the strategic objective “to increase the capacity of mental health and addictions service providers to identify those living with concurrent disorders through use of recommended screening and assessment tools”. In the comments section of the survey, both sectors identified the need for standardized instruments and training in their use.
Interestingly, in the report from the survey conducted seven years ago, recommendations included training on how to access service in the other sector, education on concurrent disorders, development of a standardized screening tool, and coordination and collaboration between mental health and addictions.
References
Bois, Christine (2003). Concurrent Disorders Priority Plan 2003-2004. Toronto:Centre for Addiction and Mental Health.
Health Canada. (2001). Best Practices: Concurrent Mental Health and Substance Use Disorders. Ottawa: Ministry of Public Works and Government Services.
Melinyshyn, M., Christie, R., Shirley, M. (1996). Travelling the Same Road: A report on concurrent disorders in Ontario. Toronto: Addiction Research Foundation.
