Co-occurring Mental Health and Substance Use Disorders

1.0 Introduction

A co-occurring disorder1 refers to the combination of mental/emotional/psychiatric

problems and the abuse of alcohol and/or other psychoactive drugs (Health Canada,
2002). It is commonly known that mental health disorders and problematic
substance use frequently co-occur, particularly among specific populations. This
clinical reality typically results in a substantial negative impact on many areas of an
individual’s life—impacts that often far exceed the effects of any one disorder alone.

2.0 Prevalence

The most recent population survey in Canada, the Canadian Community Health
Survey (CCHS; Cycle 1.2), estimates that in the general population, co-occurring
substance use and mood or anxiety disorders is relatively rare at 1.7% (1.4% among
females, 2.1% among males; Rush, Urbanoski, Bassani, Castel, & Wild, in press).
However, in particular clinical subgroups, these rates increase substantially. For
example, among individuals with substance use problems, 15.9% also have a mood
or anxiety disorder. This percentage increases to 26.3% if one considers only those
individuals with a drug disorder (Rush et al., in press).

3.0 Clinical Implications

There are a number of clinical implications of which health care professionals in

primary health care settings should be cognizant:

* Co-occurring disorders results in an elevated risk for incarceration (Abram &

Teplin, 1991), violence (Swartz et al., 1998), higher rates of relapse (Swofford,
Kaschkow, Scheller-Gilkey & Inderbitzen, 1996), homelessness (Caton et al., 1994),
and victimization (Goodman, Rosenberg, Mueser & Drake, 1997).2

* Co-occurring disorders are often associated with concurrent physical health

conditions and are generally at an increased risk of mortality (Fridell & Hesse,
2006). They are also at greater risk of HIV and hepatitis C infections (Rosenberg, et
al., 2001), diabetes, hypertension, heart disease, asthma, gastrointestinal disorders,
skin infections, malignant neoplasms and acute respiratory disorders (Dickety,
Normand, Weiss, Drake & Azeni, 2002).

* The increased prevalence among specific subpopulations has prompted a call for
standardized and universal screening for both disorders when an individual presents
with symptoms of either a substance use or mental disorder (Health Canada, 2002).

4.0 Service Use/Treatment Seeking

Individuals with a co-occurring disorder are more likely to seek treatment or

supports, compared to those who have only one disorder. Based on CCHS data,
among those who met the criteria in the previous 12 months for a co-occurring
disorder, 50.6% sought help in 2001. This is compared to only 13.6% of those with
pure substance dependence and 44.1% of those with a mood or anxiety disorder
(Rush et al., in press). The most common source of help among the co-occurring
group was a general practitioner, with 34.6% reporting seeking care from this
service (Urbanosi, Rush, Wild, Bassani, & Castel, 2007). Unfortunately, individuals
with a co-occurring disorder are also more likely to report perceived unmet need, as
compared to both the general population and those with only substance use or
mental disorder (adjusted odds ration=3.25; 95% CI=1.96-5.37; Urbanoski, Cairney,
Bassani, & Rush, 2008).

5.0 Evidence-Based Treatment and Support

Individuals with a co-occurring disorder have historically received treatment and

supports for their mental and substance use disorders from separate systems of
care. In addition to the challenges associated with navigating two separate systems,
often with different messaging and philosophies of care, evidence in recent years
has highlighted the ineffectiveness of this type of parallel treatment for this
population (Drake, Mueser, Brunette & McHugo, 2004). A review conducted in 2002
by Health Canada, called for integrated care for individuals with a co-occurring
disorder. Integration, at the program level, was defined as:

"... mental health treatments and substance abuse treatments are brought by the
same clinicians/support workers, or team of clinicians/support workers, in the same
program to ensure that the individual receives a consistent explanation of
illness/problems and a coherent prescription for treatment rather than a
contradictory set of messages from different providers." (Health Canada, 2002, pg.
vii).

While individuals with a co-occurring disorder are not likely to receive intensive
treatment within the context of a primary care setting, the guiding principles of
integrated treatment still apply (summarized from Mueser, Noordsy, Drake, & Fox,
2003):

* Integration – Primary care physicians should adopt an integrated approach to

mental health and substance use problems, including assessment, treatment
planning and crisis planning.

* Comprehensiveness – Co-occurring disorders negatively impact several life

domains, requiring a multi-pronged approach which may include residential
services, case management, supported employment, family psychoeducation, social
skills training, training in illness management and pharmacological treatment

* Assertiveness – Those with co-occurring disorders require assertive outreach and

engagement to keep them involved in effective treatment and supports.
* Harm Reduction – Many patients having a co-occurring disorder may not be
prepared, for example, to abstain from substances, or to seek treatment for their
substance use or mental disorders. They can, however, be presented with options to
reduce the negative consequences of their disorder, such as reducing the amount of
substances they use, or using clean needles for those involved in injection drug use.

* A Long-Term Perspective (Time Unlimited Services) – Individuals with a co-

occurring disorder typically take several years or more to recover from their
symptoms and to adopt a healthier lifestyle. During this time, relapses are
considered a normal part of recovery, and services and supports over the long-term
can minimize both the number of relapses and the negative consequences
associated with them.

* Motivation-Based Treatment - A staged approach to treatment is indicated to

correspond to the varying stages of readiness to change. The stages of treatment
include engagement, persuasion, active treatment and relapse prevention.
Clinicians should be sensitive to their patients’ stage of change and adapt their
clinical approach accordingly.

* Multiple Psychotherapeutic Modalities – There are a number of treatment

modalities with demonstrated clinical effectiveness among individuals with a co-
occurring disorder. A recent systematic review by Drake, O’Neal, & Wallach (2008)
concluded that group counseling, contingency management,3 and long-term
residential treatment have the most empirical evidence regarding efficacy. Other
interventions, such as family intervention, case management, shorter-term
residential treatment, do not appear to have the same impact on reducing
substance use, but do positively improve other life areas.4

6.0 Resources

Health Canada. (2002). Best Practices: Concurrent Mental Health and Substance Use
Disorders. Ottawa, ON: Author.

Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L. (2003). Integrated treatment for
dual disorders: A guide to effective practice. New York: Guilford Press.

O’Grady & Skinner, W.J.W. (2007). A Family Guide to Concurrent Disorders. Toronto,
ON: Centre for Addiction and Substance Abuse.

http://www.camh.net/Publications/Resources_for_Professionals/Partnering_with_famil
ies/partnering_families_famguide.pdf

Skinner, W.J.W., O’Grady, C.P., & Bartha, C. (2004). Concurrent Substance Use and
Mental Health Disorders: An Information Guide. Toronto, ON: Centre for Addiction
and Substance Abuse.

http://www.camh.net/About_Addiction_Mental_Health/Concurrent_Disorders/Concurr
ent_Disorders_Information_Guide/concurrent_disorders_info_guide.pdf

Center for Substance Abuse Treatment. (2006). Screening, Assessment, and

Treatment Planning for Persons With Co-Occurring Disorders. COCE Overview Paper
5. DHHS Publication No. (SMA) XX-XXXX. Rockville, MD: Substance Abuse and Mental
Health Services Administration, and Center for Mental Health Services, 2006.

http://coce.samhsa.gov/cod_resources/PDF/OP5Practices%28web%2912-18-06.pdf

Center for Substance Abuse Treatment. Understanding Evidence- Based Practices

for Co-Occurring Disorders. COCE Overview Paper 5. DHHS Publication No. (SMA) XX-
XXXX. Rockville, MD: Substance Abuse and Mental Health Services Administration,
andCenter for Mental Health Services, 2006.

Center for Substance Abuse Treatment. Services Integration. COCE Overview Paper
6. DHHS Publication No. (SMA) 07-4294. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2007.

http://coce.samhsa.gov/cod_resources/PDF/OP6-ServicesIntegration-8-13-07.pdf

http://coce.samhsa.gov/cod_resources/PDF/ScreeningAssessment(OP2).pdf

7.0 References

Abram, K.M., & Teplin, L.A. (1991). Co-occurring disorders among mentally ill jail
detainees: Implications for public policy. American Psychologist, 46, 1036-1045.

Caton, C.L.M., Shrout, P.E., Eagle, P.F., Opler, L.A., Felix, A.F., & Dominquez, B.
(1994). Risk factors for homelessness among schizophrenic men: A case-control
study. American Journal of Public Health, 84, 265-270.

Dickey, B., Normand, S.T., Weiss, R.D., Drake, R.E., Azeni, H. (2002). Medical
morbidity, mental illness, and substance use disorders. Psychiatric Services, 53,
861-867.

Drake, R.E., Mueser, K.T., Brunette, M.F., & McHugo, G.J. (2004). A review of
treatments for people with severe mental illnesses and co-occurring substance use
disorders. Psychiatric Rehabilitation Journal, 27(4), 360-374.

Drake, R.E., O’Neal, E.L., & Wallach, M.A. (2008). A systematic review of
psychosocial research on psychosocial interventions for people with co-occurring
severe mental and substance use disorders. Journal of Substance Abuse Treatment,
34, 123-138.

Flynn, P.M., & Brown, B.S. (2008). Co-occurring disorders in substance abuse
treatment: Issues and prospects. Journal of Substance Abuse Treatment, 34(1), 36-
47.

Fridell, M., & Hesse, M. (2006). Psychiatric severity and mortality in substance
abusers: A 15-year follow-up of drug users. Addictive Behaviors, 31(4), 559-565.

Goodman, L.A., Rosenberg, S.D., Mueser, K.T., & Drake, R.E. (1997). Physical and
sexual assault history in women with serious mental illness: Prevalence, correlates,
treatment, and future research directions. Schizophrenia Bulletin, 23(4), 685-696.

Health Canada. (2002). Best Practices: Concurrent Mental Health and Substance Use
Disorders. Ottawa, ON: Author.

Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L. (2003). Integrated treatment for
dual disorders: A guide to effective practice. New York: Guilford Press.

Rosenberg, S.D., Goodman, L.A., Osher, F.C., Swartz, M., Essock, S.M., Butterfield,
M.I., Constaine, N., Wolford, G.L., & Salyers, M. (2001). Prevalence of HIV, hepatitis B
and hepatitis C in people with severe mental illness. American Journal of Public
Health, 91, 31-37.

Rush, B.R., Fogg, B., Nadeau, L., & Furlong, A. (2008). On the Integration of Mental
Health and Substance Use Services and Systems. Ottawa, ON: Canadian Executive
Council on Addictions.

Rush, B.R., Urbanoski, K., Bassani, D., Castel, S. & Wild, T.C. (in press). The
epidemiology of co-occurring substance use and other mental disorders in Canada:
Prevalence, service use and unmet needs. In J. Cairney & D. Streiner (Eds.) Mental
Disorder in Canada: An Epidemiological Perspective. University of Toronto Press.

Swartz, M.S., Swanson, J.W., Hiday, V.A., Borum, R., Wagner, H.R., & Burns, B.J.
(1998). Violence and mental illness: The effects of substance abuse and
nonadherence to medications. American Journal of Psychiatry, 155, 226-231.

Swofford, C.D., Kasckow, J.W., Scheller-Gilkey, G., & Inderbitzin, L.B. (1996).
Substance use: A powerful predictor of relapse in schizophrenia. Schizophrenia
Research, 20, 145-151.

Urbanoski, K.A., Cairney, J., Bassani, D.G., & Rush, B.R. (2008). Perceived unmet
need for mental health care for Canadians with co-occurring mental and substance
use disorders. Psychiatric Services, 59(3), 1-7.

Urbanoski, K.A., Rush, B.R., Wild, T.C., Bassani, D.G., & Castel, S. (2007). Use of
mental health care services by Canadians with co-occuring substance dependence
and mental disorders. Psychiatric Services, 58(7), 962-969.

1 There are a number of terms used in the research literature regarding the overlap
of mental and substance use disorders. Originally termed ‘dual diagnosis’,
particularly in the United States, the terminology has recently changed to reflect the
reality that there can be more than just two disorders present at any one time.

2 Based on Drake et al’s (2008) review.

3 Contingency management refers to the “systematic provision of incentives and/or

disincentives for specific behaviors for the purpose of modifying those behaviors”
(Drake et al., 2008).

4 It is interesting to note that in Drake et al.’s (2008) review, program integration

seems to be a foregone conclusion, (Rush, Fogg, et al., 2008) however, an earlier,
qualitative systematic review by Donald, Dower & Kavahagh (2005) conclude that
the findings for integrated treatment are “equivocal” and that more research is
warranted. Flynn and Brown (2008) argue that treatment outcomes may be
dependent on the severity of the mental disorder and that single-disorder treatment
for individuals with a co-occurring disorder can also be effective, again, depending
on the severity.