Co-Occurring Disorders: A Hopeful Update
Sometimes called dual diagnosis, this condition is common, confounding, and entirely treatable.
The great news right off the bat: We’re discovering better ways to treat people with co-occurring disorder, which is when a person has both a substance use disorder (SUD) and a mental illness such as depression, anxiety disorder, or PTSD.
That’s an especially welcome development as nearly 10 million adults in the U.S. have a co-occurring disorder or dual diagnosis. That includes 30% to 60% of people living with SUD.
Another sobering stat: People with SUD are around twice as likely than the non-addicted population to have anxiety disorder or other types of mood-related mental health disorders.1
The evolution of treatment for co-occurring disorder
Co-occurring disorder has been around for a long time, but we just didn’t recognize it. Now we do, and the treatment for it is improving. Up until a few decades ago, SUD and mental illness were usually treated separately.
When I worked with veterans in the VA hospital system years ago, for example, we would first help them quit their substance use, then address their mental illness.
Now we treat these disorders concurrently right from the outset, in a completely integrated way. This is proving to be more effective. These days, when people go into rehab for SUD treatment, they normally start treatment for their mental illness (if needed) as soon as they get through detox.
Why did this take so long?
This is one of those times in medicine and addiction treatment when you think…why didn’t we figure out this protocol sooner? Of course it makes sense to tackle these two health conditions concurrently.
What it took was seeing certain patients relapse quickly after leaving treatment. That didn’t make clinical sense, and it made all of us in the addiction treatment field look harder at the treatment strategies we were using.
Eventually we realized we were getting people sober for the short-term, but we weren’t solving for the co-existing mental illness that was in many cases causing or exacerbating the SUD—and making people relapse at higher rates.
That’s when we realized we had to start looking at this challenge more holistically during treatment. The results continue to validate the new thinking, as long-term prognoses are improving for people with co-occurring disorder.
What comes first, the substance abuse or the mental illness?
The classic chicken versus egg question! The answer is similarly complicated. Many times, and this may be the most common scenario with co-occurring disorders, someone with a mental illness will self-medicate with drugs and/or alcohol as a way to deal with their depression, trauma, or anxiety disorder. At which point they’re off and running with their dual diagnosis/co-occurring disorder.
Other times, a person’s chronic substance use can lead to mental illnesses like depression, mood or eating disorders, and even psychosis or schizophrenia. Which, again, simply means that he or she needs to be treated in an integrated manner. Regardless of the path a person takes to the co-occurring disorder, there’s always hope, and there’s always a way forward to long-term sobriety and mental health.
The trauma/addiction connection
The Substance Abuse and Mental Health Services Association (SAMHSA) defines trauma as events or experiences that create long-lasting adverse effects for people. Trauma can occur because of physical, emotional, or sexual abuse, war or natural disasters, and for many other reasons.2 All types of trauma increase your risk of substance use disorder.
Trauma experienced during childhood may cause serious long-term effects. Officially known as Adverse Childhood Experiences (ACEs), these traumas include being abused or neglected, being frequently intimidated or humiliated by adults, witnessing violence, not having enough to eat, experiencing frequent loneliness, or growing up in a household where there are serious mental health or substance use issues.
Research also shows that the more ACEs a young person experiences, the greater their risk of SUD and other mental and physical health conditions. So there’s an additive effect.
How common are ACEs? According to the CDC, a recent survey across 25 U.S. states found that 61 percent of adults experienced at least one ACE during their childhood. More than 15 percent of adults experienced four or more ACEs.3
Given these statistics, it’s no surprise that many addiction treatment centers, including Lakeview Health, are now providing what is called “trauma-informed care.”
Screening has become standard operating procedure now
The addiction treatment field is at the point where we screen incoming patients for mental illness right away. That’s standard at most centers—certainly the good ones. (NOTE: If you, a loved one, or a friend seeks addiction treatment, always ask about a facility’s ability to screen for and treat co-occurring disorders.) To screen people for depression, for example, we use the PHQ-9 test protocol. For anxiety disorder, it’s the GAD-7 test. And so on.
Everyone gets a psychiatric evaluation when they come to Lakeview Health. You meet individually with a member of our medical team, and this expert does a detailed screening of your mental and emotional health.
Customizing treatment for co-occurring disorders
As for the treatment that then needs to happen, many addiction treatment centers now have specialists on staff whose training is in various mental illnesses. At the very least, existing staff therapists and M.D.s receive supplemental training in mental illness so they can recognize symptoms, tailor their treatment programs, and handle the integrated treatment requirements.
At Lakeview Health, if a new patient is assessed with a mental illness along with addiction, members of our multidisciplinary team create a mental health treatment plan that is customized to your specific co-occurring disorder.
Furthermore, all of our staff—from therapists to nurses to cooks to the maintenance team—receive trauma-informed care training.
Care for PTSD, anxiety, and depression disorders
Our approach is working. The proof comes from three of the most common mental illnesses we see among our co-occurring disorder population at Lakeview Health: PTSD, anxiety, and depression.
In an internal study, the rates of symptoms of those three conditions in our patients at admission were 42 percent (PTSD), 40 percent (anxiety), and 29 percent (depression). At discharge, when patients had completed their treatment, those rates dropped to 8 percent, 5 percent, and 4 percent respectively. Wow.
All of this looks like progress to me—and it is. The heightened awareness and improved protocols for treating co-occurring disorder are helping patients get better like never before. That’s wonderful news.
Addiction Treatment at Lakeview Health