Over the past twenty years, the world has changed at a rapid pace.
Treatment for SUD and mental health disorders has changed, but these changes occurred in context of changes across our entire culture and society.
Think back to the year 2000: the information age had arrived, home computers were relatively common, most people had cell phones, and we were in the early stages of doing most of our personal communication via email, text, or direct messaging.
Then, in 2007, with the introduction of smartphones, the rise of social media apps, and the widespread use of digital technology at work, home, and school, we entered the world we live in now: instant connectivity is the rule, rather than the exception, and on the horizon, we see the advent of virtual reality in the form of things like 3-D gaming and the metaverse.
That’s the future.
But we’ll stop there, and shift focus. Our daily lives have changed dramatically, thanks to advances in information technology. The way we communicate, consume media, and work and play have changed. As we mentioned above, those aren’t the only things that have changed in the first two decades of the 20th century.
Addiction treatment and mental health treatment have also changed dramatically.
We’ll start with the terminology.
We now use the phrase substance use disorder (SUD) instead of addiction. That’s a big deal, because when we combine it with a person-first approach to treatment, it reduces stigma and increases the number of people who seek help. Think about the difference between these two statements:
A junkie looking for drug rehab.
A person with a substance use disorder seeking treatment.
One is disrespectful and stigmatizing, while the other is respectful and welcoming. After the terminology, we’ve also changed our understanding of SUD. Rather than viewing it as a moral failing or lack of willpower, we now understand it as a medical condition that responds well to evidence-based treatment.
And finally, over the past 20 years we’ve changed the way we offer treatment and support to people diagnosed with a substance use disorder and a mental health disorder at the same time: we now use the integrated treatment model to treat this phenomenon, which we call co-occurring disorders.
What are Co-Occurring Disorders?
Let’s clarify our terminology.
When a person receives a diagnosis for one or more substance use disorders and one or more mental health disorders at the same time, they receive a dual diagnosis and have co-occurring disorders. In the context of SUD treatment, this is always what these terms mean. In other areas of healthcare, dual diagnosis may refer to the presence of two conditions or diseases at the same time, but the more appropriate phrase is comorbidity, while co-occurring disorders or dual diagnosis is the preferred term in mental health and SUD treatment.
Co-occurring disorders are far more prevalent than most people realize. In fact, in the introduction to the 2020 to the Substance Abuse and Mental Health Services Administration (SAMHSA) publication “SAMHSA TIP 42: Substance Use Disorder Treatment for People With Co-Occurring Disorders,” a leading expert on SUD and mental health treatment observes:
“Comorbidity is important because it is the rule rather than the exception with mental health disorders.”
The most recent data on supports this observation. The 2020 National Survey on Drug Use and Health (2020 NSDUH) shows:
- 74 million adults in the U.S. had either SUD or any mental health disorder (AMI)
- 21 million adults had SUD but not AMI
- 53 million adults had AMI
- 36 million adults had AMI but not SUD
17 million adults had SUD and AMI
- 47 million adults in the U.S. had either SUD or a serious mental health disorder (SMI)
- 32 million adults had SUD but not SMI
- 14 million adults had SMI
- 5 million adults had SMI but not SUD
5.7 million adults had SUD and SMI
Those are the big-picture facts about co-occurring disorders: we’ve defined the phenomenon and offered the latest prevalence rates. Next, we’ll focus on rates of treatment among those two groups of people with co-occurring disorders: the 17 million adults with SUD and AMI, and the 5.7 million adults with SUD and SMI.
Evidence Based Treatment for Co-Occurring Disorders: Who Received Treatment?
We know that in most cases, when a substance use disorder goes untreated, it gets worse. We also know the same is true of a mental health disorder. Without treatment, symptoms most often escalate, alongside the negative impact on family, work, and school life.
We know integrated treatment helps people recover from SUD and manage the symptoms of a mental health disorder.
But how many people with co-occurring disorders get the treatment they need?
Here’s the latest evidence from SAMHSA:
- Among the 17 million adults with SUD and AMI:
- 8.5 million – about 50% – received either SUD or mental health (MH) treatment
- 7.2 million – about 42% – received only MH treatment
- 423,000 – about 3% – received only SUD treatment
- 960,000 – almost 6% – received both SUD and MH treatment
- Among the 5.7 million adults with SUD and SMI:
- 3.7 million – about 66% – received either SUD or MH treatment
- 3.1 million – about 55% – received only mental health treatment
- 89,000 – about 1.5% – received only SUD treatment
- 529,000 – about 9% – received both SUD and mental health treatment
Let’s back up and connect a couple of dots before we phrase this data another way. First, we know that with regards to substance use disorder, co-occurring disorders are the norm, rather than the exception. Second, we know data shows the most effective treatment for co-occurring SUD and mental health disorders is the integrated treatment model. Third, the integrated treatment model means treating SUD and mental health disorders simultaneously, which means – in the language of the statistics above – receiving both SUD and MH treatment.
That’s why these facts are cause for alarm:
Among the 17 million adults with SUD and AMI, 8.4 million received no treatment at all, and only 1.0 million received treatment for both SUD and AMI.
Among the 5.7 million adults with SUD and SMI, 1.9 million received no treatment at all, and only 529,000 received treatment for both SUD and SMI.
In other words, 95 percent of people with SUD and AMI didn’t receive the treatment they needed, and 90 percent of people with SUD and SMI didn’t receive the treatment they needed. That difference is called the treatment gap. We can close the treatment gap by getting people with co-occurring disorders the treatment they need, which is – as we’ve mentioned several times in this article – integrated treatment.
We’ll explain what that means now.
What is Integrated Treatment for Co-Occurring Disorders?
We’ve hinted at a definition of integrated treatment already, by mentioning that it’s the gold-standard, evidence-based approach to treating people with co-occurring disorders. Integrated treatment is part of a broader movement in healthcare, as elucidated by the World Health Organization (WHO):
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
With regards to substance use and mental health, that means health is more than the absence of substance use or the absence of mental health symptoms. The Centers for Disease Control (CDC) concurs with this definition, and indicates their goals for all people in the U.S.:
- Help people live fulfilling lives, free from preventable disease, disability, injury, and premature death
- Establish health equity, eliminate disparities and barriers to car, and improve the health of all groups
- Promote quality of life, healthy development, and health behavior in all areas of life
Integrated treatment acknowledges these definitions and goals for overall health and includes them in treatment for co-occurring disorders. The general idea is that treatment should address not only the SUD or mental health disorders themselves, but all the factors in the life of an individual that may contribute to the SUD or mental heath disorder. Addressing and resolving symptoms is important, but the absence of symptoms is not necessarily synonymous with overall health and wellbeing.
That’s the goal of integrated treatment: total health.
Here are the primary elements of the integrated treatment model, as defined by SAMHSA.
Integrated Treatment: Six Core Components
To meet the criteria established by SAMHSA for a fully integrated SUD/Co-Occurring Disorders treatment program, a treatment center:
1. Provides Access
- Access means the process by which an individual first encounters the treatment experience. There are four main types of access:
- Routine: individuals who are not in crisis seek treatment independently
- Emergency: individuals who initiate treatment because of a crisis
- Outreach: individuals in need but do not seek treatment independently
- Involuntary: individuals who initiate treatment as mandated by an employer, the criminal justice system, or the child welfare system
- No Wrong Door
- This concept it crucial: it means that an individual should receive access to treatment no matter how they arrive at, initiate, or encounter the opportunity to engage in treatment. If an individual asks for help, help them.
- Providers can create the right door through outreach
2. Performs a Comprehensive Assessment
- Providers must screen for SUD and mental health disorders immediately
- Type of SUD/mental health disorder
- Severity of SUD/mental health disorder
- Providers must assess background:
- Family history
- Trauma history
- Medical history
- Work history
- SUD treatment history
- Providers must assess psychosocial factors:
- Employment status
- Housing status
- Food access status
- Assessments must be followed by treatment evaluations during the treatment process:
- Determine treatment progress
- Make changes to treatment plan if necessary
3. Determines an Appropriate Level of Care
- Providers us the Level of Care Utilization System (LOCUS) or similar metric to refer an individual to the appropriate level of care. The LOCUS matrix uses six factors to hep clinicians determine a level of care:
- Risk of Harm: Is the individual a risk to themselves or others?
- Functional Status: Is the individual impaired with regards to family, work, and school?
- Medical or Psychiatric Factors: Are there additional conditions or disorders that will impact treatment?
- Home Environment: Does the individual have a safe, recovery friendly home or family situation?
- Treatment History: Has the individual been in treatment before?
- Engagement/Recovery Status: Does the individual understand their disorder? Is the individual committed to treatment?
4. Achieves Integration of Treatment
- Providers address SUDs and mental health disorders concurrently, based on symptoms and need
- Clinicians receive training in treating individuals with SUD and mental health disorders
- Treatment occurs in phases that match individual readiness for treatment and engagement
- Providers use motivational strategies such as motivational interviewing (MI) to facilitate readiness and engagement
- Providers offer substance use and alcohol counseling services
- Providers offer:
- Individual therapy
- Group therapy
- Family therapy
- Peer support, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)
- Medication-assisted treatment when appropriate
5. Provides Comprehensive Services
- In this context, comprehensive means everything not mentioned above. Comprehensive services for people in treatment for co-occurring disorders may include:
- Vocational support/access to vocational services
- Housing support/ access to housing services
- Food support/access to food support services
- Language support for non-native English speakers
6. Ensures Continuity of Care
- Continuity of care refers to two things:
- Transitions between levels of care during formal treatment
- Ongoing care after the completion of a formal treatment program, which is often called aftercare or alumni support
- The goal of continuity of care between levels of care is to facilitate a smooth transition, capitalize on treatment progress, and communicate all relevant details about treatment from one treatment team to the next
- The goals of an aftercare plan – i.e. a plan an individual receives upon completion of a formal treatment program – include, but are not limited to:
- Sustaining sobriety
- Continuing recovery
- Living independently
- Resolving relationship and family issues
- Finding employment
- Continuing healthy, recovery friendly habits, such as health eating and exercising
- Ongoing engagement with a peer support/recovery community such as AA or NA
The intentional combination of the treatment components above increases the chance of successful recovery for a person diagnosed with co-occurring substance use and mental health disorders. The idea is to treat both disorders simultaneously, and, while doing so, begin to address the psychosocial factors at play that can either promote or impair the recovery process. When a person receives evidence-based treatment for all the disorders for which they receive a diagnosis, and receives support in all the areas of life that impact recovery, then their chances of achieving sustainable, long-term recovery improve.
Treating the Whole Person
The movement toward integrated treatment often involves components which we never would have considered twenty years ago. Lifestyle changes, exercise, diet, meditation, yoga, and stress management – just 20 years ago – may have been considered radical or woo woo or simply ineffective treatments with no evidence to support them.
There is now evidence to support those complementary approaches, and high-quality treatment centers around the country incorporate these components into treatment programs every day.
In addition, treating substance use and mental health disorders at the same time was not common: that’s a new approach, based on evidence – see our SAMSHA link above – that shows treating one without treating the other can impair treatment progress for both.
The final piece of the puzzle, with regards to integrated treatment, is the widespread recognition of the importance of the psychosocial components of recovery, which align with the WHO definition of health and the CDC goals for a health society that we list earlier in this article. Health is more than the absence of disease: health is when a person thrives in all areas of life.
The same is true for recovery from SUD and mental health disorders. Health is not simply abstinence from substances or the absence of mental health symptoms, although those are critical elements of health for person with SUD and a co-occurring disorder. Health is when a person thrives in recovery, maintains positive relationships, meets personal responsibilities, and achieves overall wellbeing and life satisfaction.
That’s what integrated treatment can do for an individual in recovery: create a foundation for long-term health and happiness. It takes work and commitment – and for people new to treatment, those goals can seem a long way off – but it’s important for anyone in treatment to understand this fact:
Those goals are achievable.
Right now, across the country, millions of people are finding hope in treatment, belief in themselves, and creating a positive vision of a better tomorrow.