Models of care

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Prior to discussing specific treatment options, mention needs to be made of the various models that have been proposed to treat comorbid conditions. Four approaches have been suggested (see Table 28):

  • Sequential treatment.
  • Parallel treatment.
  • Integrated treatment.
  • Stepped care.

There has been much discussion of models of care for clients with comorbid conditions, but very little research is available to determine which models may suit which comorbidities. AOD workers need to make pragmatic decisions as to which model is most appropriate for individual clients.

The idea of integrated treatment for two disorders has considerable intuitive appeal, and presents a number of advantages over other treatment approaches. Integrated treatment by a single service helps to ensure that there is a single point of contact (the client does not ‘fall through the gaps’), there are common objectives, treatment is internally consistent, the relationship between AOD use and mental health conditions may be explored, and communication problems between agencies do not interfere with treatment [32]. 

While applying an integrated treatment approach to comorbidity is appealing, there has been very little research undertaken comparing the different models [380]. Many studies examining the efficacy of integrated treatments compare them with a ‘treatment as usual’ control group, so these designs cannot establish the efficacy of integrated treatment relative to parallel or sequential treatment. However, there is some emerging evidence to suggest that integrated treatments may be superior to parallel or sequential treatments in terms of improving outcomes for mental health and substance use [381-384]. There is also growing support for the use of a stepped care approach to treating comorbidity [385-387].

Table 28: Approaches to treating comorbid AOD and mental health conditions

Sequential treatment
The client is treated for one condition first which is followed by treatment for the other condition. With this model, the AOD use is typically addressed first then the mental health problem, but in some cases it may be whichever disorder is considered to be primary (i.e., which came first).
Parallel treatment
Both the client’s AOD use and mental health condition are treated simultaneously but the treatments are provided independent of each other. Treatment for AOD use is provided by one treatment provider or service, while the mental health condition is treated by another provider or service.
Integrated treatment
Both the client’s AOD use and mental health condition are treated simultaneously by the same treatment provider or service. This approach allows for the exploration of the relationship between the person’s AOD use and his/her mental health condition.
Stepped care
Stepped care means the flexible matching of treatment intensity with case severity. The least intensive and expensive treatment is initially used and a more intensive or different form of treatment is offered only when the less intensive form has been insufficient.