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Co-Occurring Disorders Back to Course Index

 

 

What Comes First: Addiction or Mental Illness?

All people are different when it comes to their experience with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.

Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life.

Still, others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.

Formerly known as dual diagnosis or dual disorder, co-occurring disorders describe the presence of both mental health and a substance-use disorder.

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder, while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or that other health issues need to be addressed first. In any case, the consequences of undiagnosed untreated, or under-treated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Increasing awareness and building capacity in service systems are important in helping identify and treat co-occurring disorders. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services.

The term co-occurring disorder replaces the terms dual disorder and dual diagnosis when referring to an individual who has a co-existing mental illness and a substance-use disorder. While commonly used to refer to the combination of substance use and mental disorders, the term also refers to other combinations of disorders (such as mental disorders and intellectual disability).

Clients with co-occurring disorders (COD) typically have one or more disorders relating to the use of alcohol and/or other drugs, as well as one or more mental disorders. A client can be described as having co-occurring disorders when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from another disorder.

Common examples of co-occurring disorders include the combination of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism, and poly-drug addiction with schizophrenia and borderline personality disorder with episodic poly-drug abuse. Thus, there is no single combination of co-occurring disorders; in fact, there is great variability among them.EDC 

The combination of a substance use disorder and a psychiatric disorder varies along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Additionally, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

People with co-occurring disorders often experience more severe and chronic medical, social, and emotional problems than people experiencing a mental health condition or substance-use disorder alone. Because they have two disorders, they are vulnerable to both relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric distress, and the worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specifically designed for the unique needs of people with co-occurring disorders. Compared to patients who have a single disorder, patients with co-existing conditions often require longer treatment, have more crises, and progress more gradually in treatment.

 

Terms

Over time, numerous terms have been used to describe co-occurring disorders and their treatment.

Substance Abuse, Substance Dependence, and Substance-Induced Disorders

In the DSM-IVTR, substance-related disorders are divided into substance use disorders and substance-induced disorders.

Substance use disorders are further divided into substance abuse and substance dependence.

There are 11 categories of substance use disorders (e.g., disorders related to alcohol, cannabis, cocaine, opioids, nicotine), which are separated by criteria into abuse and dependence. The term “substance abuse” has come to be used informally to refer to both abuse and dependence. By and large, the terms “substance dependence” and “addiction” have come to mean the same thing, though debate exists about the interchangeable use of these terms.

Finally, the system of care for substance-related disorders is usually referred to as the substance abuse treatment system.

Substance-induced disorders are important to consider in a discussion of co-occurring disorders. Although they actually represent the direct result of substance use, their presentation can be clinically identical to other mental disorders. Therefore, individuals with substance-induced disorders must be included in co-occurring disorder planning and service delivery.

Substance abuse, as defined in the DSM-IV-TR, is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.

Classes of Substance Use Disorders

-Alcohol
-Amphetamine or similarly acting sympathomimetics
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Nicotine
-Opioids
-Phencyclidine (PCP) or similarly acting arylcyclohexylamines
-Sedatives, hypnotics, or anxiolytics

 

Substance dependence is “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems.   This maladaptive pattern of substance use includes all the features of abuse and additionally such features as:

  • Increased tolerance for the drug, resulting in the need for ever greater amounts of the substance to achieve the intended effect.
  • An obsession with securing the drug and with its use
  • Persistence in using the drug in the face of serious physical or psychological problems

Substance-induced disorders include substance intoxication, substance withdrawal, and groups of symptoms that are “in excess of those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention.

Substance-induced disorders present as a wide variety of symptoms that are characteristic of other mental disorders such as delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction.

To meet diagnostic criteria, there must be evidence of substance intoxication or withdrawal, maladaptive behavior, and a temporal relationship between the symptoms and the substance use must be established. Clients will seek care for substance-induced disorders, such as cocaine-induced psychosis, and co-occurring disorder systems must be able to address these conditions.

 

Mental Disorders

The standard use of terms for non–substance-related mental disorders also derives from the DSM-V. These terms are used throughout the medical, social service, and behavioral health fields.

The major relevant disorders for co-occurring disorders include schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, and personality disorders.

The major relevant categories of mental disorders that frequently occur with substance abuse issues include:

  • Schizophrenia and other psychotic disorders
  • Mood disorders
  • Anxiety disorders
  • Somatoform disorders
  • Factitious disorders
  • Dissociative disorders
  • Sexual and gender identity disorders
  • Eating disorders
  • Sleep disorders
  • Impulse-control disorders
  • Adjustment disorders
  • Personality disorders
  • Disorders usually first diagnosed in infancy, childhood, or adolescence

 

5 Most Common Mental Disorders Associated with Specific Addictions

Some conditions seem destined to come in pairs. Heart disease often follows a diagnosis of diabetes, for example, and allergies often come hand in hand with asthma. The same sort of joining effect sometimes takes hold when an addiction is in play. In fact, it’s quite common for certain drugs of abuse to be entangled with specific mental health disorders.  

These are five of the most common mental health/addiction combinations in play today.

 

Alcoholism and Antisocial Personality Disorder

Alcohol abuse is associated with a number of mental health concerns, including:

  • Mania
  • Dementia
  • Schizophrenia
  • Drug addiction

According to the National Institute on Alcoholism (NIAAA), antisocial personality disorder (ASPD) has the closest link with alcoholism, as people who drink to excess on a regular basis are 21 times more likely to deal with ASPD when compared to people who don’t have alcoholism. Often, the two disorders develop early in life, the NIAAA says, but alcoholism can make the underlying mental illness worse, as people who are intoxicated might have lowered inhibitions, which makes their antisocial behaviors more prevalent.  

 

Marijuana Addiction and Schizophrenia

It’s not unusual for people who have schizophrenia to develop addictions. In fact, a study in the American Journal of Psychiatry suggests that about half of all people with schizophrenia also have a substance abuse disorder. However, there’s a particularly striking association between marijuana abuse and schizophrenia. It’s unclear why people with schizophrenia would abuse this drug, as it seems to produce many of the same symptoms these people experience when in the midst of a schizophrenic episode, but it is clear that marijuana abuse is at least somewhat common in those who have schizophrenia.

 

Cocaine Addiction and Anxiety Disorders

People who abuse cocaine often take the drug because it makes them feel euphoric and powerful. However, continued use seems to lead to symptoms that are more indicative of an anxiety disorder, including:

  • Paranoia
  • Hallucinations
  • Suspiciousness
  • Insomnia
  • Violence

These symptoms may fade away in people, who achieve long-lasting sobriety, but sometimes the damage lingers, and the unusual thoughts and behaviors stick around even when sobriety has taken hold.

 

Opioid Addiction and PTSD

Post-traumatic stress disorder (PTSD) is a mental illness that takes hold in the aftermath of a very serious episode in which the person was either facing death or watching someone else die. Often, people who survive these episodes emerge with very serious physical injuries, and often, those injuries are treated with prescription painkillers. These drugs can also boost feelings of pleasure and calm inside the brain, and sometimes people who have PTSD are moved to abuse their drugs in order to experience euphoria. While people in physical pain do need help to overcome that pain, blending PTSD with painkillers can lead to tragic outcomes that no one wants.

 

Heroin Addiction and Depression

While heroin can make users feel remarkably pleasant in the short term, long-time users can burn out the portions of the brain responsible for producing signals of pleasure. In time, they may have a form of brain damage that leads to depression. They’re physically incapable of feeling happiness unless the drug is present. This drug/mental illness partnership is remarkably common, but thankfully, it can be amended with treatment and sobriety.

 

Symptoms

The symptoms of co-occurring disorders include those associated with the particular substance abuse and mental health conditions a person has. Co-occurring disorders can be difficult to diagnose because the symptoms of substance abuse or dependence can mask the symptoms of mental illness, and vice versa.

As stated, substance abuse is a maladaptive pattern of substance use that occurs despite the individual’s experiencing significant substance-related problems. Individuals who abuse substances may experience such harmful consequences of substance use as repeated failure to fulfill roles for which they are responsible, legal difficulties, or social and interpersonal problems. It is important to note that the chronic use of an illicit drug still constitutes a significant issue for treatment even when it does not meet the criteria for substance abuse.

For individuals with more severe or disabling mental disorders, as well as for those with developmental disabilities and traumatic brain injuries, substance use at lower levels might be more harmful (and therefore defined as abuse) than for individuals without such disorders.

People with co-occurring disorders are at high risk for many additional problems such as symptomatic relapses, hospitalizations, financial problems, social isolation, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses such as HIV and hepatitis B and C, and early death. Anyone of these problems complicates the treatment of co-occurring disorders.

 

Causes

Mental health and substance abuse disorders often occur as a result of biological and environmental factors. Mental disorders and addiction are each a dynamic process, with varying degrees of severity, rate of progression, and symptom manifestation. Both types of disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk), and some drugs are more likely than others to cause psychiatric or substance use disorder problems (pharmacologic risk).

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Mental illness can lead people to use alcohol or drugs to make themselves feel better temporarily. In other cases, a substance-abuse disorder triggers or in some other way leads to severe emotional and mental distress.

 

Treatments

To provide appropriate treatment for co-occurring disorders, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services recommends an integrated treatment approach. Integrated treatment is a means of coordinating substance abuse and mental health interventions, rather than treating each disorder separately and without consideration for the other.

Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. Integrated treatment may include the following:

  • Help patients think about the role that alcohol and other drugs play in their life. People feel freer to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
  • Offer patients a chance to learn more about alcohol and drugs—how they interact with mental illnesses and with other medications—and to discuss their own use of alcohol and drugs.
  • Help patients become involved with supportive employment and other services that may help the process of recovery.
  • Help patients identify and develop recovery goals. If a person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated treatment can help that person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
  • Provide counseling specifically designed for people with co-occurring disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

All substance-abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with CODs. It is the responsibility of each provider to identify clients with both mental and substance use disorders and to assure them that they have access to the care needed for each disorder.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with COD’s. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location where clients are based on the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), client fears of being seen as mentally ill (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not the diagnosis. The four quadrants are

I.  low addiction/low mental illness severity
II.  low addiction/high mental illness
III. high addiction/low mental illness
IV.  high addiction/high mental illness

The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers in order to deliver appropriate care to every client with co-occurring disorders.

 

Medication

Many clients with COD require medication to control their psychiatric symptoms. Pharmacological advances over the past decade have produced antipsychotics, antidepressants, anticonvulsants, and other medications with greater effectiveness and fewer side effects. With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives.

 

Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance-abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse-prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use drugs or drink.

 

Group Therapy

Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.

 

Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings. Some offer several hours of weekly treatment, which can include mental health and other support services as well as individual and group counseling for substance abuse. Others provide minimal services, such as one or two brief sessions, to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Individuals with COD often need a range of services besides substance-abuse treatment and mental health services. Generally, important needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse-prevention interventions after outpatient treatment need to be modified so that clients can recognize symptoms of psychiatric or substance abuse relapse on their own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly since the return of psychiatric symptoms can often trigger a substance-abuse relapse.

The Medical System

Although not substance-abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health interventions do occur in medical units. Acute care refers to short-term care provided by intensive-care units, brief hospital stays, and emergency rooms (ERs). Providers in acute-care settings are not usually concerned with treating substance-use disorders beyond detoxification, stabilization, and/or referral.

In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance-abuse treatment but may be able to provide brief interventions and treatment referrals.

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with co-occurring disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. Because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with co-occurring disorders. At that point, the person with COD can be referred for appropriate services in the proper setting.

 

Co-Occurring Disorders in Adolescents

It is estimated that between 60 to 75 percent of adolescents with mental health and/or substance abuse issues have co-occurring disorders.  Commonly documented co-occurring disorders include conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, anxiety, post-traumatic stress disorder, and substance dependence.  This co-occurrence exacts a heavy toll on adolescents and their families.

This course will explore the prevalence, warning signs, specific disorders, the role trauma plays, treatment options, and school-based supports.

Mental health and substance issues seem to go hand in hand with adolescents.  There is always much speculation about what presents first in the youth’s life, substance use, or mental health challenges.  It can happen either way and what we do know is that undiagnosed mental health problems can lead to self-medicating with substances.

  • Youth who experience a major depressive episode were twice as likely to begin using alcohol or an illicit drug compared to youth who had not experienced a major depressive episode.
  • Youth who experienced serious depression were twice as likely to use alcohol as their peers who had not been seriously depressed. Over 29 percent of youth who had not used alcohol previously initiated alcohol use following a major depressive episode within the past year, compared with 14.5 percent of youth who had not experienced a major depressive episode in the past year.
  • Similarly, much more youth who had not previously used illicit drugs did so after a major depressive episode. Sixteen percent of youth who had not used an illicit drug in the past year initiated illicit drug use after a major depressive episode, compared with 6.9 percent of youth who had not experienced a major depressive episode in the past year.

 

PREVALENCE

Approximately one in every four adolescents meets the criteria for a mental disorder that is associated with severe role impairment and/or distress.

11.2 % with mood disorders

8.3 % with anxiety disorders

9.6 % of behavior disorders  

An average of 17% of young people experience emotional, mental, or behavioral disorders.

Substance abuse or dependence was the most commonly diagnosed group of young people, followed by anxiety disorders, depressive disorders, and attention deficit hyperactivity disorder.  

The presence of both substance use and mental health concerns places teenagers at risk for a range of problems, from traffic accidents to high-risk sexual behavior and school dropout. The relationship between substance use and externalizing behavior is well-documented, but more attention needs to be paid to the substantial risks created by the co-occurrence of substance use and internalizing disorders. For instance, depression and substance use—particularly in combination—serve as primary risk factors for adolescent suicide.

According to a study published in the Journal of Abnormal Psychology, between 2009 and 2017, rates of depression among kids ages 14 to 17 increased by more than 60%. 

The increases were nearly as steep among those ages 12 to 13 (47%) and 18 to 21 (46%), and rates roughly doubled among those ages 20 to 21. In 2017—the latest year for which federal data are available—more than one in eight Americans ages 12 to 25 experienced a major depressive episode, the study found.

Among young people, rates of suicidal thoughts, plans, and attempts all increased significantly as well, and in some cases, more than doubled between 2008 and 2017.

  • 13.8 percent reported that they had seriously considered attempting suicide;
  • 10.9 percent had planned how they would attempt suicide;
  • 6.3 percent reported that they had attempted suicide one or more times within the past year; and
  • 1.9 percent had made a suicide attempt that resulted in an injury, poisoning, or an overdose that had to be treated by a doctor or nurse.

Youth from low-income households are at increased risk for mental health disorders:

  • Twenty-one percent of low-income children and youth ages 6 to 17 have mental health disorders.
  • Fifty-seven percent of these low-income children and youth come from households with incomes at or below the federal poverty level.

Those involved in the child welfare and juvenile justice systems are at even higher risk for having a mental health disorder:

  • Fifty percent of children and youth in the child welfare system have mental health disorders.
  • Sixty-seven to seventy percent of youth in the juvenile justice system have a diagnosable mental health disorder.
  • The risk for mental health problems, especially traumatic stress, is greatly increased for children living in foster care due to abuse and neglect. Children often suffer from traumatic stress after experiencing or witnessing the injury or death of someone else or otherwise feeling seriously threatened.


Access to appropriate mental health care is a significant issue. Most of the youth with mental health disorders (75-80%) do not receive services. Whether insured or not, over 75% of adolescents who could benefit are considered to have unmet mental health needs.

Youth with substance use disorders are also under-served, with less than 10% of those who could have benefited from it receiving specialty care.

 

TERMS

Over time, numerous terms have been used to describe co-occurring disorders and their treatment.

The DSM-IV-TR divides substance-related disorders into substance use disorders and substance-induced disorders.

Substance use disorders are further divided into substance abuse and substance dependence.

There are 11 categories of substance use disorders (e.g., disorders related to alcohol, cannabis, cocaine, opioids, nicotine), which are separated by criteria into abuse and dependence. The term “substance abuse” has come to be used informally to refer to both abuse and dependence. By and large, the terms “substance dependence” and “addiction” have come to mean the same thing, though debate exists about the interchangeable use of these terms.

Finally, the system of care for substance-related disorders is usually referred to as the substance abuse treatment system.

Substance-induced disorders are important to consider in a discussion of co-occurring disorders. Although they represent the direct result of substance use, their presentation can be clinically identical to other mental disorders. Therefore, individuals with substance-induced disorders must be included in co-occurring disorder planning and service delivery.

As defined in the DSM-IV-TR, substance abuse is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.

Classes of Substance Use Disorders:

Alcohol
Amphetamine or similarly acting sympathomimetics
Caffeine
Cannabis
Cocaine
Hallucinogens
Inhalants
Nicotine
Opioids
Phencyclidine (PCP) or similarly acting arylcyclohexylamines
Sedatives, hypnotics, or anxiolytics

 

Substance dependence is “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems.   This maladaptive pattern of substance use includes all the features of abuse and additionally such features as:

  • Increased tolerance for the drug, resulting in the need for ever greater amounts of the substance to achieve the intended effect.
  • An obsession with securing the drug and with its use
  • Persistence in using the drug in the face of serious physical or psychological problems

Substance-induced disorders include substance intoxication, substance withdrawal, and groups of symptoms “over those usually associated with the intoxication or withdrawal characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention.

Substance-induced disorders present a wide variety of symptoms that are characteristic of other mental disorders such as delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction.

To meet diagnostic criteria, there must be evidence of substance intoxication or withdrawal, maladaptive behavior, and a temporal relationship between the symptoms and substance use must be established. Clients will seek care for substance-induced disorders, such as cocaine-induced psychosis, and co-occurring disorder systems must be able to address these conditions.

The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not a diagnosis. The four quadrants are

  1. low addiction/low mental illness severity
    II.  low addiction/high mental illness
    III. high addiction/low mental illness
    IV.  high addiction/high mental illness

The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers to deliver appropriate care to every client with co-occurring disorders.

 

WARNING SIGNS

 

Co-occurring mental health and substance use problems can more strongly influence life outcomes and treatment for adolescents than either problem alone.  Intervention needs to be early.

Findings have revealed that compared to adolescents with substance use disorders only, those with co-occurring disorders:

  • Have an earlier onset of substance
  • Use substances more frequently.
  • Use substances over a longer period
  • Have greater rates of family, school, and legal problems
  • Have early life issues

Signs and behaviors to look for include, among others:

  • Marked fall in school performance
  • Poor grades in school despite trying very hard
  • Severe worry or anxiety, as shown by regular refusal to go to school, sleep, or participate in activities that are normal for the child’s age.
  • Frequent physical complaints
  • Marked changes in sleeping and/or eating habits
  • Extreme difficulties in concentrating that get in the way at school or home
  • Sexual acting out
  • Depression showed by sustained, prolonged negative mood and attitude, often accompanied by poor appetite, difficulty sleeping, or thoughts of death
  • Severe mood swings
  • Strong worries or anxieties that get in the way of daily life, such as at school or socializing
  • Repeated use of alcohol and/or drugs

 

COMMON DISORDERS

Research has revealed that the most common co-occurring diagnoses involve the presence of conduct disorders, mood disorders, and attention-deficit hyperactivity disorders (ADHD).  Once a conduct disorder develops, it becomes one of the strongest predictors of progression from experimentation with drugs to the development of a substance use disorder.

One study of co-occurring disorders has shown evidence that 64% (of a sample of 992 adolescents) had at least one co-occurring mental illness, with 59% meeting the criteria for conduct disorder. Fifteen percent (15%) of the sample had depression, and 13% met the criteria for ADHD. Importantly, almost all of those with any form of psychiatric co-occurrence had conduct disorder, with only 5.2% not meeting the criteria for a conduct disorder diagnosis. In substance abuse treatment settings, adolescents with juvenile-onset of bipolar disorders and schizophrenia will also be seen. Although they will not present at the same rates as adolescents with conduct disorder, ADHD, or depression, they must be evaluated fully and treated for their still-evolving mental illnesses.

Described below are some of the most common and most challenging mental health syndromes that co-occur with substance use disorders and are seen in settings treating adolescent populations.

Conduct Disorder

Symptoms/Behaviors: 
Aggression to people or animals; destruction of property; lying and theft; serious rule violations; bullying or intimidation; initiation of fights.

Associated Issues or Characteristics:
Childhood-onset (before age 10) may have more aggression, a family history of antisocial behavior, and early temperamental difficulties. In males, more evidence of direct behaviors; in females, more relational or ‘indirect’ forms may be observed. Strong association with the development of substance use disorders in adolescence.

 

Attention-Deficit/Hyperactivity Disorder (ADHD)

Symptoms/Behaviors: 
Two core categories:

1. inattention (difficulties in sustaining attention, listening, following instructions, attending to details, forgetfulness, impaired organization, and

2. Hyperactivity/Impulsivity (squirming or fidgeting, running and climbing excessively, difficulty in playing quietly, talking excessively.

Associated Issues or Characteristics:
The impairment must be observed in two or more settings; typically diagnosed in school years; features of motor activity may diminish in late adolescence/early adulthood. Consistently found more often in males. Co-occurring association with CD or Bipolar disorder predicts substance use in adolescence. Focus on immediate over delayed gratification may increase substance use risk.

 

Major Depression

Symptoms/Behaviors: 
Sad or irritable mood; changes in sleep, appetite, or body movement; not interested in previous activities; guilt or worthlessness, decreased energy; frequent thoughts of death or suicide; difficulty concentrating.

Associated Issues or Characteristics:
Suicide attempts are possible—a loss of interest in activities.  Substance use may occur as an attempt to reduce or modify symptom experience or may be associated with peer group influences.

 

Dysthymia

Symptoms/Behaviors: 
General unhappiness, pessimism, negativity, hypersensitivity to criticism, and dissatisfaction, may be hard to please, always remember feeling this way.

Associated Issues or Characteristics:
The majority of children/adolescents with dysthymia (70%) go on to develop major depression; appears to interfere more with normal development than does major depression.

 

Bipolar Disorder

Symptoms/Behaviors: 
Cycling of manic and depressive episodes; manic symptoms include irritability and agitation, sleep disturbance, distractibility/ impaired concentration, grandiosity, reckless behavior, and suicidal thought.

Associated Issues or Characteristics:
Presentation in youth may be characterized by ‘very rapid, brief, recurrent episodes lasting hours to a few days; Early-onset appears to have a greater frequency in males; Stronger association with co-occurring substance abuse, anxiety, and CD than with unipolar depression.

 

Schizophrenia (Childhood-Onset)

Symptoms/Behaviors: 
Little range of emotion, few facial expressions; poor eye contact, delays in language, unusual motor behaviors, odd speech, both in content and tone; may hear voices, ‘see’ things, problems with abstraction; may demonstrate confusion, suspicion, paranoia; unusual fears; may have few friends or be withdrawn from peers.

Associated Issues or Characteristics:
The onset of the full disorder before age 6-7; difficulty in school functioning may be an early sign; Substance use may facilitate otherwise impaired peer group interactions.

 

Anxiety

Symptoms/Behaviors:

Social trepidation and doubt, bedwetting, anger, frustration, phobias, and physical symptoms such as headaches, chest pain, tummy aches, and fatigue all can be symptoms of anxiety.

Associated Issues or Characteristics:

The average age of diagnosis is between four and eight years old, or around the time a child enters school. 

 

TREATMENT

It’s often impossible to say which problem came first.  A person may experience anxiety from childhood trauma and turn to drugs to cope, developing an addiction. Someone else may use heroin and have negative experiences that could lead to post-traumatic stress disorder. The important thing is to get help for both problems—drug problems and any other mental health disorders.  Treating co-occurring disorders can be challenging because it is difficult to understand how the two impact each other. 

Many times in treatment, substance abuse is viewed only as a means of coping with internalized mental health issues.  Other times, mental illness is viewed as a risk factor for relapse, as youth with these disorders are considered to be at risk for using substances to cope with both symptoms and consequences of their mental health disorders, including school failure, issues related to self-esteem, and difficulties in peer relationships.

 

Treatment should address the whole person through integrated treatment that addresses both substance use and other mental health disorders.

As issues begin, early intervention is key to successful treatment.  Researchers have found that half of all lifetime cases of mental illness begin by age 14 and that an untreated mental disorder can lead to a more severe, more difficult-to-treat illness, and even to the development of co-occurring mental illnesses. The onset of a mental disorder may precede substance abuse disorder.

  • Almost 90% of those with a lifetime co-occurring disorder had at least one mental disorder before the onset of a substance abuse disorder.
  • Generally, the mental disorder occurred in early adolescence (median age 11), followed by the substance abuse disorder 5 to 10 years later (median age 21).
  • The time between the onset of a mental disorder and a subsequent substance abuse disorder represents an important “window of opportunity” in which a co-occurring disorder may be prevented.

Prevention programming for children with risk factors for the development of substance use disorders and mental health disorders should be considered part of any treatment continuum. The benefit of early intervention may not only forestall or limit the likelihood that mental health disorders will be expressed but also help to derail the development of substance use disorders.

Successful prevention efforts may limit the need for more costly integrated treatment after addictions, and serious mental health disorders have developed.  Early intervention strategies, which can be school or community based, should include a focus on:

  • Pre-School students: aggressive behavior, poor social skills, academic difficulties
  • Elementary School: self-control, emotional awareness, social problem solving, academics (particularly reading)
  • Middle/High School: oppositional/defiant behavior, study habits, peer relationships, appropriate assertiveness, drug refusal skills, anti-drug attitudes.

Once significant symptoms of substance abuse or dependence and concurrent mental health disorders emerge, treating adolescents with co-occurring disorders becomes a more complex task. Treatment methods typically will include not only a focus on the individual’s psychological processes through group and/or individual interventions but will vocational/educational components and an evaluation of the family and home environment.

Treatment needs for co-occurring disorders need to be focused on:

  • Building a strong relationship and motivating clients to attend treatment
  • Creating a treatment plan that centers on client-generated goals
  • Applying empirically supported treatments, focused on interventions specific to the client’s diagnostic presentation
  • Using culturally and developmentally sensitive content
  • Focusing on client strengths, with an emphasis on impulse control, communication, problem-solving, and regulation of effect
  • Designing goals and objectives focus on sustainable change over the long term.
  • Monitoring motivation, substance use, and medication compliance, if utilized.
  • Increasing intensity if the intended response is not achieved; • Using relapse prevention strategies
  • Fostering peer group influences
  • Conducting psychoeducation for parents.

Engagement of the family in any intervention is strongly recommended as they offer the possibility of increasing the adolescent’s self-efficacy, can encourage treatment compliance, and are the primary support system for the client.

Treatment modalities frequently used with adolescents with co-occurring disorders include:

  • Multisystemic Therapy
  • Family Behavior Therapy
  • Individual Cognitive Problem Solving
  • Cognitive Behavior Therapy
  • Family Psychoeducation
  • Behavioral Family Counseling
  • Community Reinforcement Approach

Multisystemic Therapy focuses on the social and familial aspects of behavior. Treatment is thought to be best addressed by engaging multiple systems, including the family, peers, teachers, and neighbors. The treatment model focuses on:

  • Low caseloads (5-6 families)
  • Intensive treatment
  • 24/7 availability of counselors
  • Services delivered at home, school, and neighborhood centers
  • Time-limited structure (4-6 months)

Family Behavior Therapy focuses on substance abuse and behavior problems using behavioral techniques.  The intervention targets multiple domains that influence behaviors, including the family, cognitions, verbal behaviors, and social interactions. Treatment elements include:

  • Efforts at treatment engagement (calling before and after the first session, using food and drinks to engage)
  • A comprehensive assessment that is reviewed and analyzed with clients
  • Engaging siblings and peers in treatment
  • Offering a choice among other behavioral interventions, including contracting, stimulus control, and communication skills.

Individual Cognitive Problem Solving (ICPS) is focused on developing self-control and improving problem-solving. Problem-solving steps include:

  • Identifying the problem
  • Identifying choices for a response
  • Considering the consequences
  • Choosing the best option.

Cognitive Behavior Therapy (CBT) is focused on the premise that behavior is adaptive, and interaction exists between thoughts, feelings, and behaviors. Treatment focuses on learning new behaviors and using behavior modification techniques.  This model focuses on the antecedents that trigger symptoms, thoughts that arise, and feelings and behaviors associated with these thoughts. Clients are trained to monitor their maladaptive and irrational thoughts and replace them with thoughts that will produce more adaptive, healthy behaviors.

Family Psycho-education programs were developed to improve treatment coordination, assist with medication management, reduce familial conflicts, and improve problem-solving.  A consistent goal is to improve the individual’s symptoms and psychosocial functioning and reduce expressed emotion. The effort is made to engage the family within the first week of contact, to teach them about their family member’s mental illness, discuss issues in relapse, and provide ongoing problem-solving support over multiple years, if required. After the initial didactic period, the patient and family may attend sessions together.

Behavioral Family Counseling (BFC) emphasizes the role of the family in improving substance abuse outcomes.  This involves engaging family members in behavioral contracting around remaining abstinent, attending 12-step meetings, and taking medication where indicated. Sessions emphasize improving positive communication and shared activities inconsistent with substance use. Attention is given to factors that predict relapse, and training is given to facilitate coping with associated stresses.

The Community Reinforcement Approach is a multi-method intervention that includes Behavioral Family Counseling when family members are available to participate. The overarching goal of this method is to reorganize the individual’s environment so that becoming abstinent from substance use is more rewarding than continued drug use. Internal and external triggers to substance use are identified, and behavioral skills training is focused on their interruption. Job support and alternative social activities inconsistent with substance use are developed.

Group therapy provides a forum for discussing the interrelated problems of mental disorders and substance abuse, helping participants identify relapse triggers. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than act on, these impulses. Groups can also monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.

Treatment planning should be individualized.  Regardless of the therapy utilized, treatment planning is an essential component of therapy. 

 

  • Integrate all assessment info into a problem list, including the patient’s goals.
  • Engage the adolescent in treatment, initially through collaborating on goals.
  • Determine medication needs, requiring at least weekly therapy appointments, emphasizing motivational techniques and cognitive-behavioral interventions in early treatment.
  • If substance use or symptoms of psychiatric illness do not significantly improve: 1) reassess diagnosis; 2) increase the intensity or frequency of treatment.
  • Convey from the beginning an understanding of the need for long-term monitoring of psychiatric disorders, and continued attention to factors related to substance use relapse.

To achieve therapeutic gains:

  • A focus on the client’s environment, shifting away from rigidly-delivered clinically-based care.
  • A broad perspective in which life habits are modified, rather than limited, focuses on substance abuse alone.
  • The movement toward shared decision-making in the selection and delivery of treatment.
  • Establishing a strong therapeutic relationship to engage and retain clients.
  • Recognition that treatment involves a long-term process, extending months to years.

Co-occurring mental health disorders and substance use complicate the treatment process and negatively affect outcomes in both areas.  Comorbid adolescents generally show poorer treatment outcomes, more frequent treatment dropouts, and higher rates of relapse when it comes to treatment; the earlier, the better.

Recognizing that these clients are at greater risk of dropping out if their mental health disorders are not addressed, professionals in the field have to prioritize that an equivalent emphasis is placed on both categories of disorder in all treatment efforts. Knowing that adolescents may lack the maturity to understand the significant problems that can arise from unaddressed mental health problems, service settings have to develop the capacity to format their services around a long-term perspective and develop effective means to sustain these clients in treatment as they transition to programs serving adults.

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References

Wu LT, Ringwalt CL, Williams CE: Use of substance abuse treatment services by persons with mental health and substance use problems. Psychiatric Services 54:363–369,2003

Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Archives of General Psychiatry 51:8–19,1994

Substance Abuse Treatment for Persons With Co-Occurring Disorders: Treatment Improvement Protocol (TIP) Series 42. DHHS pub no SMA-05–3922. Rockville, Md, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2005

 

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