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Substance Use Disorder Treatment for People With Co-Occurring Disorders: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 42.)
People with mental illness are likely to have comorbid substance use disorders (SUDs) and vice versa. Addiction counselors should expect to encounter mental illness in their client population.
Co-occurring disorders (CODs) are burdensome conditions that have significant physical, emotional, functional, social, and economic consequences for the people who live with these disorders and their loved ones. Society as a whole is also affected by the prevalence of CODs.
Over the past two decades, the behavioral health field's knowledge of the outcomes, service needs, and treatment approaches for individuals with CODs has expanded considerably. But gaps remain in ready access to services and provision of timely, appropriate, effective, evidence-based care for people with CODs.
CODs are complex and bidirectional. They can wax and wane over time. Providers, supervisors, and administrators should be mindful of this when helping clients make decisions about treatment and level of care.
What is health? The World Health Organization (WHO) considers healthy states ones characterized by “complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, n.d.). The Department of Health and Human Services’ (HHS) Healthy People 2020 initiative also supports a broad definition of optimal health, reflected by its overarching goals of (Centers for Disease Control and Prevention [CDC], 2014):
Helping people achieve high-quality, long lives free of preventable disease, disability, injury, and premature death.
Establishing health equity, eliminating disparities, and improving the health of all groups.
Promoting quality of life, healthy development, and healthy behaviors across all life stages.
The concept of “well-being” extends beyond one's physical condition and includes other important areas of functioning and quality of life, such as mental illness and SUDs. Healthy People 2020 policy and prevention goals include reducing substance use among all Americans (especially children) and decreasing the prevalence of mental disorders (particularly suicidality and depression) while increasing treatment access (Office of Disease Prevention and Health Promotion, 2019). SUDs and mental disorders are detrimental to the health of individuals and to society as a whole. The tendency of these disorders to co-occur can make the damage they cause more extensive and complex. As knowledge of CODs continues to evolve, new challenges have arisen: What is the best way to manage CODs and reduce lags in treatment? How do we manage especially vulnerable populations with CODs, such as people experiencing homelessness and those in our criminal justice system? What about people with addiction and serious mental illness (SMI), such as bipolar disorder or schizophrenia? What are the best treatment environments and modalities? How can we build an integrated system of care?
The main purpose of this Treatment Improvement Protocol (TIP) is to attempt to answer these and related questions by providing current, evidence-based, practice-informed knowledge about the rapidly advancing field of COD research. This TIP is primarily for SUD treatment and mental health service providers, clinical supervisors, and program administrators.
This chapter introduces the TIP and is addressed to all potential audiences of the TIP: counselors, other treatment/service providers, supervisors, and administrators. It describes the scope of this TIP (both what is included and what is excluded by design), its intended audience, and the basic approach that has guided the selection of strategies, techniques, and models highlighted in the text. Next, a section on terminology, including a box of key terms, will help provide a common language and facilitate readers’ understanding of core concepts in this TIP. The chapter also addresses the developments that led to this TIP revision as well as the underlying rationale for developing a publication on CODs specifically.
The TIP summarizes state-of-the-art diagnosis, treatment, and service delivery for CODs in the addiction and mental health fields. It contains chapters on screening and assessment, diagnosis, and treatment settings and models, as well as recommendations to address workforce and administration needs. It is not intended for trainees or junior professionals lacking a basic background in mental illness and addiction (see the “Audience” section that follows). It therefore excludes generic, introductory information about mental disorders and SUDs. Of note:
The primary concern of this TIP is co-occurring SUDs and mental disorders, even though the vulnerable population with CODs is also subject to many other physical conditions. As such, co-occurring physical disorders common in individuals with SUDs, mental disorders, or both (e.g., HIV, hepatitis C virus) are beyond the scope of this publication and excluded.
Tobacco use disorder, which was treated in the original TIP as an important cross-cutting issue, is omitted from this update. Since the original development of this TIP, considerable and comprehensive treatment resources have become available specific to nicotine cessation.
Pathological gambling, which the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) classifies along with other SUDs and which was included in the original TIP, is not addressed in this update because behavioral addictions are outside its scope.
Although the TIP addresses several specific populations (i.e., people experiencing homelessness; people involved in the criminal justice system; people from diverse racial, ethnic, and cultural backgrounds; women; active duty and veteran military personnel), it does so briefly. It also omits content specifically for adolescents. The authors fully recognize, and the TIP states repeatedly, that all COD treatment must be culturally responsive.
The primary audience for this TIP is SUD treatment providers. It is meant to meet the needs of those with basic education/experience as well as the differing needs of those with intermediate or advanced education. SUD treatment providers include drug and alcohol counselors, licensed clinical social workers and psychologists who specialize in addiction treatment, and specialty practice registered nurses [psychiatric and mental health nurses]). Many such providers have addiction counseling certification or related professional licenses. Some may have credentials in the treatment of mental disorders or in criminal justice services.
Other main audiences for this TIP are mental health service providers, as well as primary care providers (e.g., general practitioners, internal medicine specialists, family physicians, nurse practitioners), who may encounter patients with CODs in their clinics, private practices, or emergency medicine settings.
Secondary audiences include administrators, supervisors, educators, researchers, criminal justice staff, and other healthcare and social service providers who work with people who have CODs.
The TIP uses three criteria for including a particular strategy, technique, or model:
Definitive research (i.e., evidence-based treatments)
Well-articulated approaches with empirical support
Consensus panel agreement about established clinical practice
The information in this TIP derives from a variety of sources, including the research literature, conceptual writings, descriptions of established program models, accumulated clinical experience and expertise, government reports, and other available empirical evidence. It reflects the current state of clinical wisdom regarding the treatment of clients with CODs.
This TIP is a resource document and a guide on CODs. It contains up-to-date knowledge and instructive material, reviews selected literature, summarizes many COD treatment approaches, and covers some empirical information. The scope of CODs generated a complex and extensive TIP that is probably best read by chapter or section.
It contains text boxes, case histories, illustrations, and summaries to synthesize knowledge that is grounded in the practical realities of clinical cases and real situations.
A special feature throughout the TIP—”Advice to the Counselor” boxes—provides direct and accessible guidance for the counselor. Readers can study these boxes to obtain concise practical guidance. Advice to the Counselor boxes distill what the counselor needs to know and what steps to take; they are enriched by more detailed reading of the relevant material in each section or chapter.
The chair and co-chair of the TIP consensus panel encourage collaboration among providers and treatment agencies to translate the concepts and methods of this TIP into other useable tools specifically shaped to the needs and resources of each agency and situation. The consensus panel hopes that the reader will gain from this TIP increased knowledge, encouragement, and resources for the important work of treating people with CODs.
Exhibit 1.1 defines key terms that appear in this TIP.
EXHIBIT 1.1. Key Terms.
The behavioral health field has used many terms to describe the group of individuals who have CODs. Some of these terms do not appear in this TIP, which attempts to reflect a “person-first” approach (see the “Person-Centered Terminology” section). Providers and other professionals working with people who have CODs need to understand that some terms that have been commonly related to CODs may now be outdated and, in certain cases, pejorative. Such terms include:
Dual diagnosis.
Dually diagnosed.
Dually disordered.
Mentally ill chemical abuser.
Mentally ill chemically dependent.
Mentally ill substance abuser.
Mentally ill substance using.
Chemically abusing mentally ill.
Chemically addicted and mentally ill.
Substance abusing mentally ill.
All of these terms have their uses, but many have connotations that are unhelpful or too broad or varied in interpretation to be useful. For example, “dual diagnosis” also can mean having both mental and developmental disorders. Outside of this TIP, readers should not assume that these terms all have the same meaning as CODs and should clarify the client characteristics associated with a particular term. Readers should also realize that the term “co-occurring disorder” is not always precise. As with other terms, it may become distorted over time by common use and come to refer to other conditions; after all, clients and consumers may have a number of health conditions that “co-occur,” including physical illness. Nevertheless, for the purpose of this TIP, CODs refers only to SUDs and mental disorders.
Some clients’ mental illness symptoms may not fully meet strict definitions of co-occurring SUDs and mental disorders or criteria for diagnoses in DSM-5 categories. However, many of the relevant principles that apply to the treatment of CODs will also apply to these individuals. Careful assessment and treatment planning to take each disorder into account will still be important.
This TIP uses only person-first language—such as “person with CODs.” In recent years, consumer advocacy groups have expressed concerns about how clients are classified. Many object to terminology that seems to put them in a “box” with a label that follows them through life, that does not capture the fullness of their identities. A person with CODs may also be a mother, a plumber, a pianist, a student, or a person with diabetes, to cite just a few examples. Referring to an individual as a person who has a specific disorder—a person with depression rather than “a depressive,” a person with schizophrenia rather than “a schizophrenic,” or a person who uses heroin rather than “a heroin addict”—is more acceptable to many clients because it implies that they have many characteristics beyond a stigmatized illness, and therefore they are not defined by this illness.
Because this TIP's primary audience is counselors in the addiction and mental health fields, this publication uses the term “client,” rather than “patient” or “consumer.”
Important developments in a number of areas pointed to the need for a revised TIP on CODs:
The revisions to the diagnostic classification of and diagnostic criteria for mental disorders in DSM-5 made an update necessary. See Chapter 4 for an indepth discussion of DSM-5 diagnoses.
This update to TIP 42 offers a greater emphasis on integrated care or concurrent treatment (e.g., treating a client's alcohol use disorder [AUD] at the same time that you treat his or her posttraumatic stress disorder [PTSD]), as this is a larger focus of the research and clinical field today than when this TIP was originally published. More information about treatment approaches is in Chapter 7.
This update reflects a wealth of new data about effective treatment options for people with CODs, including those with SMI (see especially Chapter 7).
Empirical evidence confirms that CODs are serious problems in need of better management. Treatment rates are markedly low and outcomes often suboptimal, underscoring the importance of advancing the field's knowledge about and use of appropriate, specialized techniques for screening, assessment, diagnosis, and coordinated care of this population. Findings from four key areas are borne out by prevalence statistics and other nationally representative survey data and reveal the stark reality of underservice in this population.
“Comorbidity is important because it is the rule rather than the exception with mental health disorders.”
Source: Lai, Cleary, Sitharthan, & Hunt, 2015; p. 8
National surveys suggest that mental illness (and SMI in particular) commonly co-occurs with substance misuse in the general adult population, and many individuals with CODs go untreated. The National Survey on Drug Use and Health (NSDUH), based on a sample of more than 67,700 U.S. civilians ages 12 or older in noninstitutionalized settings (Center for Behavioral Health Statistics and Quality [CBHSQ], 2019), offers revealing insights. Notable statistics from the latest survey include the following (CBHSQ, 2019):
In 2018, 47.6 million (19.1 percent of all adults) adults ages 18 and older had any mental illness during the previous year, including 11.4 million (4.6 percent of all adults) with SMI.
Among these 47.6 million adults with any past-year mental disorder, 9.2 million (19.3 percent) also had an SUD, but only 5 percent of adults without any mental illness in the past year had an SUD.
Of the 11.4 million adults with an SMI in the previous year, approximately 28 percent also had an SUD.
SMI is highly correlated with substance misuse (Exhibit 1.2; McCance-Katz, 2019). Adults ages 1 8 and older with any past-year mental illness were more likely than those without to use illicit drugs or misuse prescription medication. This pattern was even more pronounced among people with SMI. Of the 47.6 million adults with any past-year mental illness, more than half (56.7 percent) received no treatment, and over one-third (35.9 percent) of adults with an SMI in the past year received no treatment. Further, nearly all (more than 90 percent) of the 9.2 million adults with both a past-year mental illness and SUD did not receive services for both conditions (McCance-Katz, 2019).
About 14.2 million adults (about 5.7 percent of all adults) saw themselves as needing mental health services at some point in the previous year but did not receive it (CBHSQ, 2019):
Of adults with any mental disorder, 11.2 million (almost 24 percent), or nearly 1 in 4 adults with any mental illness, had a perceived unmet need for mental health services in the past year.
Of adults with an SMI, 5.1 million (about 45 percent), or more than 2 out of every 5 adults with SMI, had a perceived unmet need for mental health services in the previous year.
More than 18 million people ages 12 and older needed but did not receive SUD treatment in the previous year (e.g., they had an SUD or problems related to substance use). Most of those individuals did not see themselves as needing treatment (only 5 percent thought they needed it).
Almost half (48.6 percent) of adults ages 18 and older with any mental illness and co-occurring SUD received no treatment at all in 2018. About 41 percent received mental health services only, 3.3 percent received SUD treatment only, and 7 percent received both.
Of adults with SMI and co-occurring SUDs, 30.5 percent received no treatment. About 56 received mental health services only; almost 3 percent received SUD treatment only; and about 11 percent received both.
EXHIBIT 1.2. Co-Occurring Substance Misuse in Adults Ages 18 and Older With and Without Any Mental Illness and SMI (in 2018).
Other nationally representative survey datasets confirm the high rate of comorbidity and treatment need for mental disorders and SUDs in the general adult population. An analysis of Wave 3 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; Grant et al., 2015) revealed an increased risk of comorbid mental illness among people with 12-month and lifetime AUD. Specifically, the odds of having major depression, bipolar disorder, antisocial personality disorder (PD), borderline PD (BPD), panic disorder, specific phobia, or generalized anxiety disorder (GAD) ranged from 1.2 to 6.4. Only 20 percent of people with lifetime AUD and 8 percent of people with 12-month AUD received treatment.
From the same survey, any 12-month drug use disorder (i.e., SUD not involving alcohol) was associated with significantly increased odds of also having a co-occurring mental disorder, including 1.3 times the odds of having major depressive disorder (MDD), 1.5 odds of dysthymia, 1.5 odds of bipolar I disorder, 1.6 odds of PTSD, 1.4 odds of antisocial PD, and 1.8 odds of BPD (Grant et al., 2016). Lifetime drug use disorder had similar comorbidities but also was associated with a 1.3 increase in odds of also having GAD, panic disorder, or social phobia. Only 13.5 percent of people with a 12-month drug use disorder and about a quarter of people with any lifetime drug use disorder received treatment in the past year.
Compared with people with mental disorders or SUDs alone, people with CODs are more likely to be hospitalized. Some evidence suggests that the hospitalization rate for people with CODs is increasing.
Since the 1960s, treatment for mental disorders and SUDs in the United States has shifted away from state-owned facilities to psychiatric units in general hospitals and private psychiatric hospitals (Parks & Radke, 2014). Psychiatric bed capacity has continued to shrink over the past few decades in the United States and elsewhere (Allison, & Bastiampillai, 2017; Lutterman, Shaw, Fisher, & Manderscheid, 2017; Tyrer, Sharfstein, O'Reilly, Allison, & Bastiampillai, 2017), despite an upsurge in mental disorder/SUD-related hospitalizations:
The Agency for Healthcare Research and Quality found that from 2005 to 2014, the number of hospital inpatient stays for people with mental disorders or SUDs increased by 12 percent, and the proportion of total inpatient stays accounted for by mental disorders or SUDs also increased, by 20 percent (McDermott, Elixhauser, & Sun, 2017).
CODs are also linked to rehospitalizations for non-behavioral-health reasons (i.e., for physical health conditions). Among a large sample of Florida Medicaid recipients (Becker, Boaz, Andel, & Hafner, 2017), 28 percent of people with SMI and an SUD were rehospitalized within 30 days of discharge, whereas rehospitalization occurred in only 17 percent of people with neither disorder, 22 percent of people with SMI only, 27 percent of people with a drug use disorder, and 24 percent of people with AUD.
In the 2000 to 2012 Treatment Episode Data Set (TEDS), SUD treatment-related admissions of adults ages 55 and older that also involved cooccurring psychiatric problems nearly doubled, from 17 percent to 32 percent (Chhatre, Cook, Mallik, & Jayadevappa, 2017).
As reported in the 2012 Healthcare Cost and Utilization Project (Heslin, Elixhauser, & Steiner, 2015), almost 6 percent of all inpatient hospitalizations in the United States involved a COD, 21 percent a mental disorder diagnosis only, and about 6 percent an SUD only. Of inpatient stays involving a primary diagnosis of mental illness or SUD, 46 percent were because of a COD, whereas 40 percent of inpatient stays involved a mental disorder only and 15 percent an SUD only (Heslin et al., 2015).
OPIOID USE DISORDER AND THE PROBLEM OF CODS.
Hospitalizations and early readmissions are costly, potentially preventable occurrences. Identifying individuals at risk for either or both (such as individuals with CODs) could inform more effective discharge planning and wraparound services.
Some evidence supports an increased prevalence of people with CODs in treatment settings and of more programs for people with CODs. However, treatment gaps remain.
Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (Zhu & Wu, 2018) found that the number of people ages 1 2 and older hospitalized for inpatient detoxification who had a co-occurring mental disorder diagnosis increased significantly from 43 percent in 2003 to almost 59 percent in 2011. This included a significant rise in co-occurring anxiety disorders (8 percent vs. 17 percent) and nonsignificant but notable increases in mood disorders (35 percent vs. 46 percent) and schizophrenia or other psychotic disorders (3 percent vs. 5 percent). Recent survey data (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018e) revealed a significant increase in the proportion of clients with CODs in SUD treatment facilities from 2007 (37 percent) to 2017 (50 percent).
COD programming has not kept pace with the increase in clients needing such services. In 2018, almost every SUD treatment facility surveyed through the National Survey of Substance Abuse Treatment Services (99.8 percent) reported having clients in treatment with a diagnosed COD (SAMHSA, 2019a). However, only 50 percent of the facilities indicated that they provided specifically tailored programs or group treatments for clients with CODs.
The 2018 National Mental Health Services Survey (SAMHSA, 2019b) reported similar findings: Only 46 percent of mental health service facilities offered COD-specific programming. Facilities most likely to offer COD programming were private psychiatric hospitals (65 percent). Veterans Administration medical centers (56 percent), and multisetting mental health facilities (59 percent), and community mental health centers (54 percent). Among those least likely to offer COD programs were partial hospitalization/day treatment facilities (37 percent) and general hospitals (40 percent). A national survey of 256 SUD treatment and mental health service programs (McGovern, Lambert-Harris, Gotham, Claus, & Xie, 2014) found only 18 percent of addiction programs and 9 percent of mental health services programs were rated as COD “capable” (in terms of their capacity to adequately deliver COD services).
The types of assessment and pretreatment services at SUD treatment facilities varied in 2018 (SAMHSA, 2019a), with 96 percent providing screening for substance misuse, 93 percent providing comprehensive substance misuse assessment or SUD diagnosis, 75 percent screening for mental disorders, and 53 percent providing comprehensive psychiatric assessment or diagnosis.
CODs can complicate treatment and, if poorly managed, can hinder recovery. Further, rates of mental disorders appear to increase as the number of SUDs increases, meaning people with polysubstance use are especially vulnerable to CODs.
Epidemiologists have observed increasing rates of SUD treatment admissions among people with multiple SUDs. Analyses of TEDS data (SAMHSA, CBHSQ, 2019) reveal that in 2017, more than 25 percent of people ages 12 and older admitted for SUD treatment reported both alcohol and other substance misuse. This could partially account for the increase in clients with CODs in SUD treatment settings, as it appears that having multiple mental disorders increases the odds of having multiple SUDs or vice versa. In the NESARC-III (McCabe, West, Jutkiewicz, & Boyd, 2017), people with one lifetime mental disorder had more than three times the odds of having multiple past-year SUDs compared with people with no lifetime mental disorders. But people with multiple mental disorders (particularly mood disorders, PDs, and PTSD) are nearly nine times more likely to have multiple past-year SUDs. Individuals with multiple previous SUDs were also less likely to experience remission from substance misuse than were people with a single SUD.
SUD treatment facilities are increasingly seeing nonalcohol substances as the primary substance of misuse among people entering treatment. For instance, from 2005 to 2015, the proportion of alcohol admissions decreased from about 40 percent to 34 percent and opiate admissions increased from 18 percent to 34 percent (with opiates other than heroin increasing from 4 percent to 8 percent) (SAMHSA, 2017). This and the trend of increased polysubstance misuse are worrisome, as NESARC-III data clearly demonstrate both drug use disorders and AUD each independently confer an exaggerated risk of co-occurring mental disorders (Grant et al., 2015; Grant et al., 2016).
CODs can be an obstacle to addiction recovery, especially when untreated. Data from the 2009 to 2011 TEDS-Discharges show that, of people admitted to SUD treatment, 28 percent had a co-occurring psychiatric condition (Krawczyk et al., 2017). Prevalence rates of CODs varied across individual states and ranged from 8 percent to 62 percent. People with a psychiatric comorbidity were significantly more likely than those without a psychiatric comorbidity to report using three or more substances (27 percent vs. 17 percent). Of people who did not complete treatment, 42 percent had a COD, versus 36 percent without. This translated to about a 1.3 increase in odds of not completing treatment and a 1.1 increase in odds of earlier time to attrition for people with CODs compared with those with an SUD only.
CODs are strongly associated with socioeconomic and health factors that can challenge recovery, such as unemployment, homelessness, incarcer-ation/criminal justice system involvement, and suicide.
According to SAMHSA's Mental Health Annual Report, in 2017, 29 percent of people with CODs were unemployed and 50 percent were not in the labor force (eg., disabled, retired, student) (SAMHSA, 2019d). The current national unemployment rate at the time of this publication is 3.8 percent (Bureau of Labor Statistics, March 3, 2020).
Of people 12 and older with CODs, 7.5 percent experience homelessness, including 8.3 percent of people with an SUD and schizophrenia or other psychotic disorder, 6.9 percent with an SUD and bipolar disorders, and 7.8 percent with an SUD and depressive disorders (SAMHSA, 2019d). Rates of lifetime and past-year homelessness in the general community per NESARC-III (Tsai, 2018) are about 4 percent and 1.5 percent, respectively. The 2017 Annual Homeless Assessment Report to Congress (Henry, Watt, Rosenthal, & Shivji, 2017) found that almost 23 percent of adults in permanent supportive housing programs had transferred from an SUD treatment center; 15 percent, from a mental health services facility. Furthermore, of the 552,830 total individuals experiencing homelessness, about 20 percent (111,122) had an SMI and about 16 percent (86,647) had a chronic SUD (U.S. Department of Housing and Urban Development, 2018).
Of people incarcerated in U.S. state prisons (Al-Rousan, Rubenstein, Sieleni, Deol, & Wallace, 2017), about 48 percent have a history of mental illness (of whom 29 percent had an SMI), 26 percent, a history of an SUD. Of those with mental illness, 49 percent also have a cooccurring SUD.
Mental disorders that commonly co-occur with SUDs—including depression, anxiety disorders, bipolar disorders, schizophrenia, and PTSD—are highly prevalent in people who have completed suicide, (Stone, Chen, Daumit, Linden, & McGinty, 2019). Suicide is also a well-known risk factor in SUDs and a leading cause of death for people with addiction (Center for Substance Abuse Treatment, 2009; Yuodelis-Flores & Ries, 2015). In CDC's National Vital Statistics System dataset (Stone et al., 2019), 46 percent of all individuals in the United States who died by suicide between 2014 and 2016 had a known mental condition, and 28 percent misused substances, and of this 28 percent almost one-third (32 percent) also had a known mental health condition.
These figures reflect the need for specifically tailored COD assessments, interventions, treatment approaches, and clinical considerations (e.g., COD programming specific to people without stable housing; COD interventions designed for implementation in criminal justice settings). More information about how these variables factor into service provision and outcomes can be found in Chapters 4 and 6.
Counselors working with clients who have CODs often want to know which disorder developed first. The answer is not always clear because the temporal nature of CODs can be inconsistent and nuanced. In some cases, a mental disorder may obviously have led to the development of an SUD. An example would be someone with long-standing major depressive disorder who starts using alcohol excessively to cope and develops AUD. In other instances, substance use clearly precipitated the mental disorder—such as when someone develops a cocaine-induced psychotic disorder. In many cases, it will be uncertain which disorder occurred first.
Furthermore, CODs can be bidirectional. For some clients, there may be a third condition that is influencing both or either of the two comorbid disorders (e.g., HIV, chronic pain). Environmental factors, like homelessness or extreme stress, can also affect one or both disorders. Thus, even when it is clear which disorder developed first, the causal relationship may be unknown. Regardless of the temporal-causal relationship between a client's SLID and mental illness, the two are likely to affect, and possibly exacerbate, one another. This means that both need to be treated with equal seriousness.
In addition to inducing a mental disorder, substance misuse can sometimes mimic a mental disorder. Thus, it is important to use thorough screening and assessment approaches to help disentangle all symptoms and make an accurate diagnosis. Learn more about screening and assessment for CODs in Chapter 3.
CODs are not necessarily equal in severity. Often, one disorder is more severe, distressing, or impairing than the other. Recognizing this is important for treatment planning and requires a person-centered rather than cookie-cutter approach to determining diagnosis, comorbidities, functioning, treatment and referral needs, and stage of change. Models are available to help counselors make such decisions based on the severity and impact of each disorder. For instance, the Four Quadrants Model (National Association of State Mental Health Program Directors & National Association of State Alcohol and Drug Abuse Directors, 1999) classifies clients in four basic groups based on relative symptom severity, not diagnosis:
Category I: Less severe mental disorder/less severe substance disorder
Category II: More severe mental disorder/less severe substance disorder
Category III: Less severe mental disorder/more severe substance disorder
Category IV: More severe mental disorder/more severe substance disorder
For a more detailed description of this model, see Chapter 2. To learn how to integrate the quadrants of care framework into assessment and treatment decision-making processes, see Chapter 3.
The notion that SUDs are caused, in whole or in part, by one's attempts to “self-medicate” symptoms with alcohol or illicit drugs has been a source of debate. The consensus panel cautions that the term “self-medication” should not be used, as it equates drugs of misuse (which usually worsen health) with true medications (which are designed to improve health). Although some people with mental conditions may misuse substances to alleviate their symptoms or otherwise cope (Sarvet et al., 2018; Simpson, Stappenbeck, Luterek, Lehavot, & Kaysen, 2014), this is not always the case. Counselors should not assume self-medication is the causal link between a client's mental disorder and SUD.
The COD recovery trajectory often has pitfalls, but our understanding of CODs and COD-specific service delivery has improved over the past 20 years. Despite these advances, significant gaps remain in the accurate and timely assessment, diagnosis, and treatment of people with CODs. To achieve lower cost mental health services and SUD treatment, better client outcomes, and a more positive treatment experience, providers and administrators must collectively place more focus on CODs in their work. By better understanding the risks and responding to the service needs of people with CODs, behavioral health service providers can help make long-term recovery an attainable goal for all clients with CODs.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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