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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 cooccurring 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 cooccurring 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) XXXXXX. 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.
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