Mental health and substance use conditions often co-occur. In other words, individuals with substance use conditions often have a mental health condition at the same time and vice versa.

  • Approximately 8.9 million adults have co-occurring disorders.
  • Only 7.4 percent of patients receive treatment for both conditions, with 55.8 percent receiving no treatment at all.1

Co-occurring Disorders is a term that refers to the existence of more than one health issue in the same person, whether occurring simultaneously (independently) or sequentially (one causing the other). These terms also imply interaction between the disorders or illnesses, which affects the course and prognosis of each one individually.2

Another way to medically identify individuals who have both a mental health condition and a substance use disorder is to say they have a “dual diagnosis”. These conditions occur together frequently. In particular, alcohol and other drug (AOD) addictions tend to occur with:

  • Depression
  • Anxiety disorders
  • Schizophrenia
  • Personality disorders

Sometimes the mental problem occurs first. This can lead people to use alcohol or drugs that make them feel better temporarily. Sometimes the substance abuse occurs first. Over time, that can lead to emotional and mental problems.

What a U.S. Drug Authority Says about Co-occurring Disorders

To help explain the co-occurrence with respect to substance use disorders and mental health conditions, Nora D. Volkow, M.D. and Director of the National Institute on Drug Abuse, says we need to first recognize that drug addiction is a mental illness. It is a complex brain disease characterized by compulsive – at times uncontrollable – drug craving, seeking, and use despite devastating consequence and behaviors that stem from drug-induced changes in brain structure and function. These changes occur in some of the same brain areas that are disrupted in other mental disorders. So it is not surprising that studies show a high rate of co-occurrence between drug addiction and other mental illnesses. While we cannot always prove a connection or cause, we do know that certain mental disorders are established risk factors for subsequent drug abuse and vice versa.

It is often difficult to disentangle the overlapping symptoms of drug addiction and other mental illnesses, making diagnosis and treatment complex. Correct diagnosis is critical to ensuring appropriate and effective treatment. Ignorance of or failure to treat a dual diagnosis can jeopardize a patient’s chance of recovery.

Hopefully our enhanced understanding of the common genetic, environmental and neural bases of these disorders – and the dissemination of this information – will lead to improved treatments for dual diagnoses and will diminish the social stigma that makes patients reluctant to seek the treatment they need.2

Extensive research has documented the need to treat all conditions from which patients suffer and has identified key components of the best practices for achieving this goal. Moreover, a growing body of research suggests that integrated approaches to treatment may improve the outcome of patients.

Although optimally integrated care is still the exception in most treatment settings, interest in this approach is mounting, and many programs are attempting to incorporate integrated models of care.3

Integrated treatment works

Integrated treatment (i.e., treatment that addresses an individual’s co-occurring conditions) is associated with lower costs and better outcomes, such as:

  • Reduced substance use
  • Improved psychiatric symptoms and functioning
  • Decreased hospitalization
  • Increased housing stability
  • Fewer arrests
  • Improved quality of life

The Substance Abuse and Mental Health Services Administration – a leading national authority on both addiction and mental health – advocates an integrated treatment approach for co-occurring disorders.1

What Types of Dual Diagnosis Treatment Exist Today?

Many programs now recognize the downside of separate systems for dual diagnosis patients and are attempting to add integrative elements into their curricula. Currently, treatment models fall into four categories:

Serial Treatment – care is received in sequential treatment episodes, in separate systems of care.

Simultaneous/Parallel Treatment – care is received for disorders simultaneously, but in separate, non-coordinated systems.

Coordinated/Parallel Treatment – care for all disorders is received simultaneously in separate but well-coordinated and closely linked systems.

Integrated Treatment – care for all disorders is provided by the same cross-trained clinicians and in the same program, resulting in clinical integration of services.4

Evolving Treatment in U.S.: Compartmentalized to Coordinated, Independent to Integrated

Traditionally in the U.S., clinicians within each treatment setting – alcohol treatment, drug treatment, mental health treatment, and general medicine treatment – isolate the condition related to their specialty and treat it separately. That is, they treat their patients as though they had just one condition, and they have been relatively slow in their willingness to diagnose or treat the other existing conditions contributing to their patients’ present state.4

Until well into the 20th century, patients with alcohol problems – if they received treatment at all – received care from asylums and sanatoriums. The latter part of the 20th century saw a separation of services and study formally established.

Unfortunately, the creation of separate treatment entities created a system in which most programs and providers did not have the resources, training or inclination to treat patients with a dual diagnosis; instead, they reinforced differences in provider attitudes toward specific disorders and in overall treatment philosophy. Regrettably, this often resulted in patients being referred to one agency or another for the various types of treatment needed. Not a very effective approach.

A fundamental principle that has been emerging from research is the need to treat co-occurring conditions concurrently, which can be a rather difficult proposition. Patients who have both a drug use disorder and mental health condition often exhibit symptoms that are more persistent, severe and resistant to treatment compared with patients who have just one or the other. Nevertheless, steady progress is being made to substantiate the need for integrated treatment.5

Dual Diagnosis: Dictated by a Comprehensive Approach

The high rate of co-occurrence between drug addictions and mental health conditions argues for a comprehensive approach to intervention that identifies, evaluates and treats each disorder concurrently (i.e., calls for a dual diagnosis); treatment would be tailored to the individual’s specific co-occurring conditions and needs.

This approach calls for broad assessment tools that are less likely to result in a missed diagnosis. This means that patients entering treatment for psychiatric disorders would also be screened for addictions – and vice versa.

Accurate diagnosis is complicated, however, by the similarities between drug-related symptoms and those of potentially co-occurring mental disorders. Thus, when people who abuse drugs enter treatment, it may be necessary to observe them after a period of abstinence in order to distinguish between the effects of substance intoxication or withdrawal and the symptoms of co-occurring mental health conditions. This practice would allow for a more accurate diagnosis and more targeted and appropriate treatment.2

How Are Co-occurring Conditions Being Manifested?

The high prevalence of co-occurrence between drug abuse and mental conditions has been well documented in multiple national population studies since the 1980s. Data shows that persons diagnosed with mood or anxiety disorders are about twice as likely to also suffer from a drug use disorder compared with the general public. The same is true for those diagnosed with an antisocial syndrome, such as antisocial personality or conduct disorder. Similarly, individuals diagnosed with drug disorders are roughly twice as likely to suffer also from mood and anxiety disorders. These are just a few of the commonly co-occurring conditions being identified today.

Gender is also a factor in the specific patterns of observed co-occurrence. For example, the overall rates of abuse and dependence for most drugs tend to be higher among males than females. Males are also more likely to suffer from antisocial personality disorders, while women have higher rates of mood and anxiety disorders – all of which are risk factors for substance abuse.2

Why Do Addictions Frequently Coincide With Mental Conditions?

The high prevalence of co-occurrence between substance use disorders and mental health conditions does not mean that one caused the other, even if one appeared first. In fact, establishing causality or directionality is difficult for several reasons. Diagnosis of a mental disorder may not occur until symptoms have progressed to a significant level; however, subclinical symptoms may also prompt drug use, and imperfect recollections of when drug use or abuse started can create confusion as to which came first.

Still, three scenarios deserve consideration when contemplating the common co-occurrence of substance use disorders and mental health conditions:

  1. Drugs of abuse can cause abusers to experience one or more symptoms of another mental health condition. The increased risk of psychosis in some marijuana abusers has been offered as evidence for this possibility.
  2. Mental conditions can lead to drug abuse. Individuals with overt, mild, or even subclinical mental disorders may abuse drugs as a form of self-medication. For example, the use of tobacco products by patients with schizophrenia is believed to lessen the symptoms of the disease and improve cognition.
  3. Both drug use disorders and mental conditions are caused by overlapping factors, such as underlying brain deficits, genetic vulnerabilities and an early exposure to stress or trauma.2

What’s Keeping Treatment from Being Integrated?

There are many reasons for resistance to a more integrated approach to dual diagnosis cases in the U.S., not least of which is the fact that the various fields of treatment available today are trained to operate from the perspective of their own “bubble” of knowledge, practices and ideology. Although research supports the need for comprehensive, dual-diagnostic treatment, provision of such treatment in the U.S. can be problematic for these reasons:

• Different treatment systems continue to address drug use disorders and other mental conditions separately. Physicians are most often the front line of treatment for mental disorders, whereas drug abuse treatment is provided in assorted venues by a mix of health care professionals with different backgrounds. Thus, neither system may have sufficiently broad expertise to address the full range of problems presented by patients. People also use these health care systems differently, depending on insurance coverage and social factors. For example, when suffering from substance abuse and mental illness simultaneously, women more often seek help from mental health practitioners, whereas men tend to seek help through substance abuse treatment channels.

• A lingering bias remains in some substance abuse treatment centers against using any medications, including those necessary to treat serious mental disorders such as depression. Additionally, many substance abuse treatment programs do not employ professionals qualified to prescribe, dispense and monitor medications.

• Many of those needing treatment are in the criminal justice system. It is estimated that about 45 percent of offenders in state and local prisons have a mental health problem co-occurring with substance abuse or addiction. However, adequate treatment services for both drug use disorders and mental health conditions are greatly lacking within these settings. While treatment provision may be burdensome for the criminal justice system, it offers an opportunity to positively affect the public’s health and safety. Treatment of co-occurring disorders can reduce not only associated medical complications, but also negative social outcomes by mitigating against a return to criminal behavior and reincarceration.5

What Does Research Tell Us About Effective Dual-Diagnosis Treatment?

One study of AOD treatment patients with a dual diagnosis found that patients in programs with specialized services (e.g., a more “dual diagnosis” approach, higher percentages of clinicians with training or certification in multiple treatment areas, or access to more mental health expertise) more frequently used psychological services and had better mental health and AOD use outcomes after six months of treatment.

Another study examined the outcome impact of training psychiatric clinicians in the treatment of co-occurring disorders. It was found that patients assigned to these trained clinicians had better health outcomes at 18 months than did those who received the usual mental health services. Other findings also indicate that treatment components which increase integration of services for dual diagnosis cases may be beneficial.

Cumulatively, research is documenting the need to treat all conditions from which patients suffer (i.e., in all of their health dimensions) and has identified many key components of the best practices for achieving this goal. Moreover, a growing body of research suggests that an integrated, dual-diagnosis approach to treatment will likely improve the outcome for patients with coinciding conditions.

With the number of co-occurring disorders on the rise, evidence – and, likewise, pressure on care providers – is mounting to more thoughtfully consider how best to coordinate treatment to be more patient-centered.2

Here at Skywood Recovery, we believe strongly in providing an integrated, dual-diagnosis approach to treatment, as may be needed by our clients. We have been recognized by more than ten federally funded studies for our highly effective strategies and results in comparison to other programs nationwide. We encourage you to carefully consider all the pertinent facts before deciding which treatment provider is worthy of your trust. Skywood Recovery not only takes the approach being shown to be most effective today, but we also have the expertise and environment that we believe will be most conducive to successful results.

1 “Co-occurring Disorder”, Substance Abuse and Mental Health Services Administration, http://media.samhsa.gov/co-occurring/ .

2 “Comorbidity: Addiction and Other Mental Illnesses”, Research Report Series, National Institute on Drug Abuse, https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf .

3 “Dual Diagnosis”, MedLinePlus, U.S. National Library of Medicine, https://www.nlm.nih.gov/medlineplus/dualdiagnosis.html .

4 Sterling, Stacy, M.P.H., M.S.W., et. al., “Integrating Care for People with Co-occurring Alcohol and other Drug, Medical, and Mental Health Conditions”, National Institute on Alcohol Abuse and Alcoholism, http://pubs.niaaa.nih.gov/publications/arh334/338-349.pdf .

5 “Comorbidity: Addiction and Other Mental Illnesses”, National Institute on Drug Abuse, http://www.drugabuse.gov/publications/research-reports/comorbidity-addiction-other-mental-illnesses/how-should-comorbid-conditions-be-treated (September 2010).