Treatment of co-occurring disorders

Treatment of Co-Occurring Disorders

The simultaneous presence of both mental illness and a substance abuse disorder in a single individual, known as "co-occurring disorders" (CODs), has become the focus of attention for many behavioral health researchers, clinicians, and policymakers in recent years due to emerging evidence of the serious and challenging nature of these disorders. Within the population of individuals with serious mental illness, for example, substance use has been shown to adversely affect the course and outcome of mental health treatment ("Co-occurring disorders," n.d.).

The federal

Substance Abuse and Mental Health Services Administration (SAMHSA) recently estimated that 7.2 million Americans between the ages of 18 and 54 have CODs. Persons at risk for developing a COD include individuals with a serious and debilitating mental illness and those with a history of abusing alcohol and/or other drugs ("Co-occurring disorders," n.d.).

Dual diagnosis can be difficult to identify because the symptoms of one disorder often mimic the symptoms of the other disorder. Many of the symptoms of drug abuse, such as extreme anxiety, depression, paranoia, delusions, and hallucinations are similar to symptoms of mental illness. The impact that the symptoms have on a person's life causing severe decline in self-care, and functioning can also be a symptom of a psychiatric problem (Cutter, Elam, Jaffe, & Segal, 2008).

The families of people afflicted with a mental illness and the professionals who treat these cases can easily underestimate the severity of the person's problem with drugs or alcohol for several reasons: Drug abusers can covertly use substances without their families knowing; the behavioral signs of drug use look like the signs of a mental illness and it may be difficult to separate the two; and it takes time to unravel the interacting effects of substance abuse and mental illness (Cutter, et al., 2008).

There are eleven 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 ("Center for substance abuse treatment," 2007).

Normal, and even exaggerated, responses to stressful experiences should not be confused with a diagnosable mental disorder. Only when intense emotions, thoughts, and/or behaviors occur over extended periods of time and result in impairment in functioning are they considered mental disorders ("Center for...," 2007).

Mental disorders are characterized by: the nature and severity of symptoms; the duration of symptoms; and the extent to which symptoms interfere with one's ability to carry out daily routines, succeed at work or school, and form and keep meaningful interpersonal relationships ("Center for...," 2007)

Major Relevant Categories of Mental Disorders for COD

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

Source: APA, 2000.

So...How Prevalent is it?

37% of alcohol abusers and 53% of drug abusers have at least one mental illness.

Of all people diagnosed as mentally ill, 29% abuse either alcohol or drugs.

About 50% of people with mental disorders are affected by substance abuse.

Research has been conducted by many different government organizations and universities. The National Co-morbidity Study for instance, found that about half of the individuals participating in their survey who met criteria for a substance use disorder, also met criteria for one or more lifetime mental disorders. The same was true of those who met mental illness criteria, meaning, at some point they met the criteria for a substance use disorder ("Co-occuring disorder," 2008)

What are Some of the Mental Disorders that Occur in Co-Occurring Disorders?

Substance abuse disorders can occur with any mental illness; however, they are more likely to occur with a severe mental illness such as bipolar disorder or schizophrenia (see table above). Some of the other mental health illness with which substance abuse occurs is as follows: antisocial personality disorder, manic episode, schizophrenia, panic disorder, obsessive compulsive disorder, and with phobias. In one study conducted, forty-seven percent of people with schizophrenia also had a substance abuse disorder and sixty one percent of individuals with bipolar disorder had a substance abuse disorder. These individuals are four and five times as likely, respectively, to have a co-occurring disorder than the general population ("Co-occuring disorder," 2008).

What Type of Treatment is Available

Perhaps one of the best forms of treatment for co-occurring disorders is what is known as integrated treatment. As the name implies, the patient receives treatment for both mental illness and substance abuse from the same clinician or from a team of clinicians. The team works together to make sure that the different interventions are brought together. This way the client will see no division between mental health and substance abuse treatment. This eliminates the confusion that can often occur when obtaining treatment in two different centers. The beauty of integrated treatment is that each client has his or her specific program plan. The individual can move at his or her own pace, thereby resulting in a more effective treatment situation which will hopefully lead to long lasting recovery ("Co-occuring disorder," 2008). It must be noted that there is some dissenting opinion that this is the most effective way to treat two such different health problems (see p.9, para.2,&p.10).

Good Chance of Recovery?

Yes. Individuals with Co-occurring disorders can recover. Since treatment for such a disorder is two-fold, and those involved in treatment must remember that treatment in a dual diagnosis program will take time. Recovery should be regarded as a long-term goal, one that is attainable if proper and effective treatment is obtained. Perhaps the most difficult problem with such a disorder is identifying that it exists ("Co-occuring disorder," 2008).

Another Model

The term co-occurring disorders (COD) refers to co-occurring substance-related and mental disorders. Clients said to have COD have one or more substance-related disorders as well as one or more mental disorders. The definition of a person with COD (individual-level definition) must be distinguished from a person who requires COD services (service definition). At the individual level, COD exist "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 [a single] disorder" ("Center for...," 2007) conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not diagnosis.

The four quadrants are:

I. Low addiction/low mental illness

II. Low addiction/high mental illness

III. High addiction/low mental illness

IV. High addiction/high mental illness

This model provides a framework for understanding the range of co-occurring conditions and the level of coordination that service systems need to address them. Someone with acute mental illness symptoms and a substance use disorder can be assigned to Quadrant IV for a brief time, then drop back to a less severe quadrant. Although the four-quadrant model is not yet validated, COCE materials and technical assistance will use it to guide discussion and further conceptual development ("Center for...," 2007).

The four-quadrant model also provides a structure for moving beyond minimal coordination to fostering consultation, collaboration, and integration among systems and providers in order to deliver appropriate care to every client with COD. Coordination, consultation, collaboration, and integration are not discrete points. Rather, they reside upon a continuum. It is important to note that coordination, consultation, collaboration, and integration refer to organizational and provider behavior, and not to service systems structure or the location in which services are provided ("Center for...," 2007).

Depression...and Happiness? An Unusual Treatment Model

Depression is the leading cause of relapse for all addictions, including workaholics, gambling addiction, sex and love addiction eating disorders and so forth. The odds in favor of any addict recovering long-term are so low to begin with, that unless a dual diagnosis addiction treatment client is treated for his underlying depression, the odds against any success becomes astronomical ("Dual diagnosis...," 2006).

Hope and Serenity Dual Diagnosis and Treatment for Co-Occurring Disorder Center believes that these symptoms must be relieved or eliminated if the person is to remain clean and sober after completing his or her addiction treatment program. Depression is often anger turned inside, so the goal of their dual-diagnosis addiction treatment program is to turn the depression back into anger, then safely releasing the anger so that it can be dealt with, which effectively ends the depression.

Dual-diagnosis and treatment for co-occurring disorder means that they view substance abuse as a symptom of underlying psychological issues. People experiment with drugs or alcohol initially because of peer pressure. When that invisible line is crossed into addiction, however, the using becomes driven by depression and/or anxiety. As a dual-diagnosis program Hope & Serenity Center emphasizes the twelve-steps of recovery. Clients attend multiple twelve-step meetings and participate in twelve-step work to gain freedom from alcohol and/or drug addiction. In addition, they participate in individual and group counseling in order to alleviate the depression and anxiety underlying the addiction ("Dual diagnosis...," 2006).

Happiness, in their opinion, is the cure for addictions. Giving and receiving love is the key to happiness. This concept is the main reason for Hope and Serenity's success in treating addiction by addressing the underlying cause of the problem. This simple word love that is as old as time itself, is so overused in today's society that it get's equated with sex, control, abuse, and so forth. Hope's dual diagnosis addiction treatment staff was hired first, for their ability to show love for others and secondly, for their qualifications as therapists (also extremely high). Love is the ability to understand and empathize with another human being and their problems.("Dual diagnosis," 2006).

Different Therapy - Detoxification

Another method of treatment at other treatment centers begins with an in-residence detoxification process that allows for stabilization under the care of a physician who specializes in addiction medicine. Whether the drug of choice is cocaine, alcohol, methamphetamines, marijuana, benzodiazepines, heroin, prescription medications, or club drugs, the process of those substances leaving your system is supervised by a physician. ("Dual diagnosis programs," n.d.).

Part of the same treatment program is a brief therapy aimed at helping individuals make significant changes in their lives and their relationships with others. By focusing on new ways of thinking, behaving and interacting with others and the world around them, clients develop the skills to live their lives differently. In Solution-Focused Therapy, personal recovery goals are identified and specific strategies for achieving those goals are developed ("Dual diagnosis programs," n.d.).

Horses...Really?

Others believe that Equine Therapy, which incorporates the use of horses, facilitates positive, long lasting behavior changes. As horses are incredibly intuitive creatures, interacting with them helps to build self-esteem and a connection with something outside ourselves. A horse's sensitivity to nonverbal stimulus gives them an amazing ability to read people and reflect our emotional states back to us. Horses have an incomparable understanding of the feelings and emotional stress that a person is going through. Therapy with the use of horses can often help individuals realize truths about themselves that they never would have found otherwise Dual Diagnosis programs," n.d.).

Review of Treatment Methods

The literature shows that, over the past several decades, treatment for co-occurring disorders has undergone a broad shift in approach, from treating substance abuse before providing mental health care to providing simultaneous treatment for each disorder, regardless of the status of the co-morbid condition. Many treatment recommendations are supported by a broad consensus.

However, despite this broad agreement, recommendations are often not specific enough to guide clinical care. Most recommendations with specificity are for acute pharmacotherapy, but even specific recommendations lag behind current clinical practice. Although the use of psychotropic medication for mental illness is encouraged, experts disagree as to whether it is necessary to wait for abstinence before beginning pharmacotherapy. (Watkins, Burnham, Pincus, & Nicholson, 2005).

In addition, most diagnosis-specific guidelines are silent as to whether the specific treatment recommendation applies to co-occurring disorders. Finally, empirical evidence is lacking for most recommendations. The authors conclude that the mental health and substance abuse treatment fields need to consider its research priorities and how to address the multitude of potential combinations of disorders (Watkins, et al., 2005).

Assumptions and General Findings of Treatments Offered

Recommendations in diagnosis specific guidelines do not specifically apply to persons with co-occurring disorders. Although most diagnosis specific guidelines contain a small section documenting the importance of co-occurring disorders, diagnosis specific guidelines are often silent as to whether the specific treatment recommendations apply to co-occurring disorders. Thus there is no evidence for important treatment questions such as how long psychotropic medication should continue once symptoms have remitted, whether and for how long maintenance treatment for substance use or mental disorders is recommended, and whether methadone is efficacious for individuals with opiate addiction who have co-occurring disorders.