Integrative Management of Complex Patients with High Comorbidity

Abstract

Common patterns of comorbidity in mental illness are described and mainstream approaches to managing complex cases with high comorbidity are reviewed. Depressed mood, anxiety, psychosis, bipolar disorder, post-traumatic stress disorder (PTSD), and other serious mental health problems often occur together (i.e., “are comorbid”) with substance abuse and medical problems. Mental health problems are also frequently comorbid with medical disorders in all age groups and may significantly impact the clinical course of medical illness and response to treatment. Complex presentations involving two or more serious mental health problems and comorbid substance abuse or a medical problem are often poorly responsive to pharmaceuticals and other Western medical treatments. Managing complex cases calls for multitiered treatment planning incorporating evidence from a wide range of Western medical and CAM modalities. There is currently no agreement within Western medicine or non-Western systems of medicine on how to manage complex cases with high comorbidity. Complex patients with serious mental health problems and comorbid substance abuse or medical problems respond better and more rapidly when managed by a team of practitioners using a collaborative care model. The methodology developed in previous chapters is expanded to address complex cases with high comorbidity including co-occurring psychiatric disorders, substance abuse and medical problems. Important clinical considerations involved in managing complex patients are reviewed. The goal of parsimony is to identify the simplest care plan that adequately addresses all medical, mental health and substance use problem(s). The uses of the evidence tables and algorithms for planning integrative mental health care involving highly comorbid cases are described. The chapter concludes with a detailed case vignette that includes the rationale for recommendations made during different phases of treatment.