• The OAD Clinic

Understanding Co-Occurring Mental Health Disorders and Developing a Coherent Treatment Plan

Updated: Jul 16

Introduction

In 2014, SAMHSA revealed that approximately 7.9 million people experienced concurrent addiction and a mental health disorder. That’s nearly 40% of the entire population who experienced addiction through that year. NIDA statistics on co-occurring disorders reveal people with mood-related mental health disorders or anxiety are twice as likely to succumb to a drug disorder – and similarly, patients with substance use disorders are approximately twice as likely to be diagnosed with those types of mental health disorders.


- Approximately 50% of individuals with severe mental health disorders are affected by substance abuse.

- 37% of alcohol abusers and 53% of drug users also have at least one serious mental illness.

- Of all the people diagnosed with a mental illness, 29% abuse either alcohol or drugs.

What are Co-occurring Mental Health Disorders?

Dual diagnosis (also known as co-occurring disorders) is a term that refers to individuals

who experience a mental illness and a substance use disorder simultaneously. Each of these—substance use or mental disorder—can develop first. Individuals experiencing a mental health disorder may resort to abusing alcohol or other drugs as a mode of self-medication to improve the mental health symptoms they experience. However, research reveals that alcohol and other drugs worsen the symptoms of mental disorders.


The professional fields of substance use and mental health recovery have dissimilar cultures, so finding an integrated plan of care can be a huge challenge.


Two entwined problems – What Should You Expect with a Dual Diagnosis?

Co-occurring disorders tend to be difficult to diagnose. Symptoms of substance abuse or alcohol addiction can mask symptoms of mental disorder, and symptoms of mental illness can be muddled with addiction symptoms. Individuals with mental health disorders occasionally do not address their substance use since they don't believe it to be relevant to their illness.


However, here are some typical patterns that emerge with co-occurring disorders:


A worsening course of mental health symptoms even while getting treatment.

People diagnosed with mental illnesses often use substances to attain emotional satisfaction. People with anxiety may seek something to make them feel calm; people with depression may abuse a substance to make them feel more animated; people having specific phobias may seek something to make them feel less inhibited and more relaxed; and people suffering from psychological pain may seek substances to make them feel numb.


Alcohol Addiction or the use of other drugs not only results in treatment failure for the mental disorder but also prevents the patient from developing sufficient coping skills, creating satisfying relationships, and making peace with themselves. Alcohol also interferes with the drugs prescribed for mental health disorders. Briefly, drug and alcohol use worsens any mental health disorder.


Substance or alcohol use problems that seem treatment-resistant.

Individuals with co-occurring disorders may stop abusing alcohol or other drugs, but they will experience difficulties as their mental health disorders symptoms persist. Treatment centres, clinicians and addiction specialists may not be well-equipped to address the co-existence of both conditions. And some conventional peer recovery groups may advocate abstinence from all forms of drugs – even the prescription medications for mental health disorders. Resultantly, people with co-occurring disorders find it challenging to treat their substance-use disorder simultaneously with their mental health disorders.


Why is it Important to Devise a Coherent Treatment Plan?

The association of Co-occurring AUD and MHCs with poorer outcomes, like increased relapse rate, use of emergency services, as well as the use of psychiatric services, when compared to individual disorder – is the biggest factor that calls for an integrated intervention.


Co-Occurring disorders were not increasingly recognised until the 1980s and 1990s, and patients presenting for SUD or mental health treatment frequently were not evaluated for a co-occurring disorder, or they were prescribed treatment plan without addressing the co-occurring disorder. Since neither of these disorders is likely to show clinical improvement if treated in isolation without acknowledging the influence or presence of the co-occurring disorder, different treatment approaches were developed to counter co-occurrence, inclusive of parallel, sequential, and integrated treatments. Sequential treatment refers to assessing or treating one disorder before the other one. While in parallel treatment, each disorder is addressed separately by different clinicians or treatment teams. The integrated treatment refers to an approach where the same provider or treatment team addresses both disorders simultaneously.


What are the Types of Integrated Therapy?

In addition to diagnosing the presence or absence of co-occurring AUD or MHCs, elucidating the nature, chronicity, scope, and effect of the primary disorder and the co-occurring ones is critically significant for creating an effective recovery and treatment plan. The heterogeneity among co-occurring AUD and MHCs, calls for individualised treatment plans that account for the severity of each disorder and patient preference when it comes to devising interventions


The integrated therapy should consist of:


Behavioural therapy

Behavioural therapies, consist of cognitive behavioural therapy, motivational enhancement therapy, contingency management, and 12-step facilitation – referred to as the standard of care for individuals with AUD and consolidating a chief part of a treatment plan for patients with co-occurring AUD and MHCs. Behavioural therapy for AUD – commonly consisting of motivational enhancement therapy or cognitive behavioural therapy, is offered to all participants in most randomised controlled trials that assess pharmacotherapy for patients with AUD and an MHC. When it comes to AUD-focused therapies delivered to patients with MHCs, the plan of delivery needs to be adapted to account for the MHC.


Pharmacotherapy

Owing to the global literature on pharmacotherapy for co-occurring AUD and MHCs, the argument can be constructed that that medication in the absence of treatment interventions may not be sufficient to stabilise both conditions. Nonetheless, medication remains a treatment option in patients with co-occurring disorders. Initial stabilisation and maintenance with disorder-specific medication are specifically required in more serious mental illness, like bipolar disorder and psychotic disorders. For MHCs, like anxiety and depression with mild to moderate impairment and AUD with mild impairment, the clinical guidelines suggest medication or therapy as first-line treatment options. However, medication is more strongly indicated for individuals who have a greater impairment.


Community support

Peer-led mutual help organisations can be another constituent of a treatment plan for individuals with co-occurring AUD and MHCs.

Dealing with a dual diagnosis can feel isolating and challenging. Support groups or


Alcohol rehab clinics enable members to share frustrations, celebrate successes, find specialists referrals, find the best community resources and exchange recovery tips. They also offer a space for forming healthy relationships filled with encouragement to stay sober. Here are some groups NAMI likes:


- Double Trouble refers to a 12-step fellowship for individuals managing a co-existing mental illness and substance abuse.

- 12-step groups like Alcoholics Anonymous Narcotics Anonymous, for individuals recovering from alcohol or drug addiction.

- Smart Recovery – a sobriety support group for people with a variety of addictions that is not based on faith.


All these groups follow the 12 phases or traditions of 12-step organisations, but they contain modifications addressing the co-occurring MHC.


The Verdict?

According to The Journal of the National Institute on Alcohol Abuse and Alcoholism:


“Evidence-based practices for integrated treatment programs for individuals with substantial impairment and low functioning because of AUD and a serious mental illness, such as schizophrenia or bipolar disorder, include incorporating interventions that match an individual’s stage of readiness for treatment engagement and involve assertive outreach, motivational interventions, and counseling to build cognitive and behavioral skills. Evidence-based practices also include strengthening an individual’s connection with social supports that encourage recovery, a comprehensive approach that addresses AUD and MHCs in all aspects of the program, including social services, and takes a long-term, community-based perspective on recovery. Cultural sensitivity and competence are also crucial aspects of integrated treatment programs.”


References:

https://www.arcr.niaaa.nih.gov/arcr401/article07.htm?utm_source=GovD&utm_medium=Email&utm_campaign=Issue-401-Article-7

https://www.mdedge.com/familymedicine/article/207657/mental-health/caring-patients-co-occurring-mental-health-substance-use

https://www.samhsa.gov/


Image references:

https://www.mentalhelp.net/content/uploads/2015/09/1-mental-illness-new.png

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