Forging a path for improved treatment of comorbid mental health and substance use conditions

It is well known that many people accessing treatment for substance use in the New South Wales public health system also experience a mental health problem – estimates suggest up to three quarters of people, or almost 75%.

However, the traditional ‘siloed’ nature of health service funding and operations means people with both conditions cannot receive all the treatment they need in one setting. NSW Health has been aware the nature of health service funding and operations can make it difficult for people to receive all the treatment they need in one setting and various strategies have been tried to lessen the challenges faced by patients, carers and clinicians and the broader healthcare system. 

In 2016, researchers led by Professor Paul Haber, a University of Sydney addiction medicine specialist, received funding from the NSW Health Translational Research Grants Scheme. They aimed to develop and evaluate a new approach to comorbidity treatment, with the ultimate objective of providing a more integrated approach to care. 

Haber and his colleagues, including Professor Maree Teesson, had previously demonstrated the effectiveness of an integrated care approach – using cognitive behavioural treatment and motivational enhancement for comorbid social anxiety and alcohol use disorders – in a randomised controlled trial across two Sydney hospitals. Attempting to improve the management of comorbid substance use and mental illness on a larger scale was the next logical step.  

The team used a multimodal translation intervention package, Pathways to Comorbidity Care, to upskill counsellors and psychologists across six local health services. The package included training in the identification, screening and management of comorbid mental health conditions in patients seeking treatment for substance use disorders.  

A multi-angle approach 

The multimodal training offered an online portal with background information and evidence-based approaches for each comorbid condition. Sections of these resources were developed in collaboration with the National Drug and Alcohol Research Centre and the NSW Agency for Clinical Innovation.   

Webinars, seminars and clinical supervision were also provided to clinicians and managers from the Sydney, South Western Sydney, Central Coast, Hunter, New England, and Mid North Coast local health districts as part of the training program.  

Significant increases in the identification of comorbid mental health conditions were observed in the six months after the intervention, along with improvements in treatment of comorbid conditions and enhanced clinician knowledge, attitudes and perceptions of comorbid conditions.  

Collaboration the key to success 

Local clinical champions were crucial to the intervention’s success. They served as an ongoing point of contact and knowledge base for health service staff, conducting regular group workshops to supplement the training received as part of the program.  

“Having someone within the service that was championing the program on the ground was an important and effective strategy,” said co-investigator Professor Kirsten Morley.  

A qualitative examination of barriers and facilitators to successful implementation of the program reinforced the importance of clinical champions to the project’s success. It also identified organisational, resource and behavioural factors limiting the program’s effectiveness.  

“It’s not as simple as putting up a website and saying, ‘problem solved’. Because we tried that, and the problem was not solved,” Haber said.  

Haber and Morley believe the Pathways to Comorbidity Care program has long-term potential and can be upscaled to other settings. This includes expanding it beyond substance use, and to other local health districts across the state. 

“Although patients with comorbid substance use and mental health disorders often attend mental health settings for treatment, we did not implement this project in that space. Going beyond drug and alcohol settings represents a greater opportunity for value gain, but it would be a substantial new project,” Haber explained.  

Other jurisdictions are also interested in the training package. 

“Victoria have approached us to use the training package to upskill their clinicians in integrated care,” Morley added.