Key Researchers


Key Results: Substance Abuse and Co-occurring Disorders

Citations Listed in Key Results

  • Responding positively to a national call to action, both mental health and substance abuse treatment systems and providers are highly motivated to improve the quality of services for persons already under their care and who have co-occurring disorders.
    For many years, substance abuse systems and providers were inaccurately seen as "resistant" or unwilling to address mental health issues, and were believed to perceive integrated psychiatric services as counter to traditional addiction treatment and twelve step recovery approaches (McGovern and McLellan, 2008).
  • Epidemiological studies consistently find high rates of co-morbidity risk across substance use and psychiatric disorders. In the most recent study, the presence of a psychiatric disorder more than doubled the odds of having a substance use disorder.
    The National Epidemiologic Survey on Alcohol and Related Conditions sought, via in-depth diagnostic interviews of a representative sample of adults in the United States, the prevalence and association of substance use disorders and independent mood and anxiety disorders. The prevalence rates of 12-month DSM-IV independent mood and anxiety disorders in the U.S. population were 9.21% (19 million) and 11.8% (21.8 million) respectively. Estimates are that over 9.35% (or 20 million) U.S. adults suffer from a substance use disorder (17.6 million alcohol; 4.2 million drug). Having a mood disorder increases the odds of having a substance dependence disorder by 4.5x compared to the risk in populations without a mood disorder, and having any anxiety disorder nearly triples the odds of having a substance use disorder (Grant et al, 2004).
  • In population studies, having a substance use disorder, particularly a drug use disorder, is associated with having a co-existing mental health disorder.
    In one epidemiological study in particular, the focus was on examining the risk for mental health disorders, based on the lifetime presence of a substance use disorder. The percentages and increased odds for having a co-occurring mental health disorder by specific substances were: Cocaine 76.1% (11.3x), Barbiturates 74.7% (10.8x), Hallucinogens 69.2% (8x), Opiates 65.2% (6.7x), and Alcohol 36.6% (2.3x) (Regier et al, 1990).
  • Even though rates of co-morbidity are high in epidemiological studies, they are even higher among clinical samples, including persons in addiction treatment.
    The Grant et al (2004) epidemiological study noted above found that rates of co-occurring disorders were 2-3x higher among individuals in treatment. The highest rates are found in institutions, including inpatient and outpatient mental health clinics, correctional facilities, and addiction treatment programs. Although the estimates and measures vary by study, a recent study placed the following rates of psychiatric disorders in addiction treatment settings: mood disorders including bipolar disorder (40%), anxiety disorders (28%), posttraumatic stress disorder, (28%), Axis II disorders (20%), and schizophrenia (less than 5%) (Cacciola et al, 2001).
  • Addiction treatment providers estimate that 60-80% of clients also have an active and often untreated mental health problem. This makes treatment more challenging, increases the chances for premature attrition, and adds to the likelihood of relapse.
    In a 2006 study by McGovern et al, a self-report survey was administered to 453 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40-42%), anxiety disorders (24-27%), posttraumatic stress disorder (24-27%), severe mental illnesses (16-21%), antisocial personality disorder (18-20%), and borderline personality disorder (17-18%). These estimates correspond to the Cacciola et al (2001) review of the research findings and underscore the concern of community treatment providers about providing better care for clients already in their services.
  • If they receive standard care, the outcomes for persons with co-occurring substance use and psychiatric disorders are poor. On the other hand, the evidence is clear that integrated treatments for both disorders are associated with significantly improved outcomes.
    In a landmark study of the outcomes of 742 individuals with substance use disorders, of those with significant psychiatric severity, there was no benefit from addiction treatment including reduction of substance use and psychiatric symptoms, or within legal, medical, and social/family problem areas. Of those with moderate psychiatric severity, improvement depended upon the availability of psychiatric services to target these problems (McLellan et al, 1983).

    In a review of 45 controlled studies (22 experimental and 23 quasi-experimental) Drake, Mueser, and Brunette (2007) conclude the evidence for integrated treatments is consistently strong and replicated. One specific model, Integrated Dual Disorder Treatment (IDDT) has been widely disseminated and supported by SAMHSA as an evidence-based practice for persons with severe mental illness and substance use disorders.
  • Even in the case of the most common co-morbidity, depression and alcohol use disorder, treating only the depression with anti-depressant medication results in little improvement in either the substance use or the mood disorder.
    In a meta-analysis of over 300 citations, 14 studies, and 848 patients, the conclusion is that anti-depressant medication alone for persons with co-occurring mood and alcohol use disorders is not effective. The study authors recommend that if anti-depressants are indicated, then integrated treatment specifically targeting the substance use problem is also warranted (Nunes and Levin, 2004).
  • Most persons with co-occurring disorders do not receive services for either mental health or substance use (53.5%), and the few who do receive services get treatment for both disorders concurrently (10.4%). The proportion receiving integrated treatment is less than 2%.
    In a household survey conducted by SAMHSA, an estimated 5.4 million adults have co-occurring "severe psychological distress" and substance use disorders. Most did not receive services (53.5%), 33.3% received mental health care only, 2.8% received addiction treatment only, and 10.4% received concurrent but not integrated services (SAMHSA, 2008).
  • While there is substantial interest among federal agencies in improving access to integrated services for persons with co-occurring disorders, few specific guidelines and resources, particularly for addiction treatment providers, have been offered.
    A 2008 paper by Clark et al links the epidemiological and available services utilization data from the large population studies and treatment episode data sets available to SAMHSA. A variety of initiatives have been implemented by the federal agency (SAMHSA) to promote a “No wrong door” access to services. In particular, through SAMHSA Co-Occurring State Incentive Grant funding, states and providers were enabled through resources and planning to develop local solutions to problems of access, treatment services, and workforce development. Although there were some commonalities in solutions, there was also significant variation. Questions remain about how to sustain these initiatives in the absence of grant funding and in the face of declining state block grant funding that incentivizes the bifurcation of services.

    Based on the current American Society of Addiction Medicine Patient Placement Criteria (ASAM-PPC-2R) a theoretical taxonomy of addiction treatment program dual diagnosis capability was designed: Addiction Only Services (AOS) are programs that treat only persons with substance use disorders and exclude those with psychiatric disorders of any severity or acuity; Dual Diagnosis Capable (DDC) services are those programs that treat persons with co-occurring disorders but only if these conditions are relatively stable; Dual Diagnosis Enhanced (DDE) programs are programs that accept and treat persons with psychiatric disorders regardless of severity or acuity. This framework lacked operational definitions but paved the way for more practical determination and potential measurement of the range of available services to persons with co-occurring disorders (Minkoff et al, 2003).
  • Given the current status of health care funding and policy, it will be important for research to guide practice. It is imperative that we ascertain which persons can be treated by general practitioners, and which persons need specialized treatment. Policy should support patient access and transition among these services and develop a cadre of professionals adept at assessing and treating these co-occurring conditions.
    In addition to receiving a "call to action" to improve services to persons with co-occurring disorders, both addiction and mental health providers are operating in policy and financial conditions with stable or decreased funding. On the surface, it appears treatment providers are being asked to do more with less, but in reality the majority of the patients they already see have co-occurring disorders. So, the issue is really how to improve the quality of care for existing patients, given the current realities of funding and policy. Although there is substantial evidence that persons with co-occurring psychiatric disorders do not fare well in standard addiction treatment, and likewise persons with co-occurring substance use disorders fare less well in standard mental health treatment, more research is needed in this area. Specifically, it is necessary to identify what level of severity of the co-occurring disorder may require specialized care outside of the addiction or mental health program. This is important because several studies show that persons with co-occurring disorders do as well as persons with substance use disorder only (in addiction treatment programs) or mental health disorders only (in mental health programs) (Flynn and Brown, 2008).
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