Dual Diagnosis: Barriers and Gateways to Effective Addiction Care
October 3, 2020
Addiction to drugs or alcohol often coexists with one or more other mental health conditions. A 2018 study found that nearly 48% of American adults with a substance use disorder had at least one other psychiatric disorder.
Among adults aged 18 or older in 2018:
- 57.8 million adults had a substance use disorder or other type of mental illness
- 19.3 million adults had a substance use disorder
- 9.2 million adults had a substance use disorder and at least one other type of mental illness
Overcoming Traditional Approaches to Care
Not surprisingly, having more than one disorder presents treatment challenges, but challenges that can be overcome. According to R. Kathryn McHugh, PhD, a clinical psychologist and director of the Stress, Anxiety, and Substance Use Laboratory at McLean Hospital, the traditional care model for co-occurring disorders is perhaps the biggest hurdle to effective treatment.
“Historically, mental health treatment and substance use treatment are done in different places, by different people,” explained McHugh. “People are trained in one or the other discipline, and they don’t necessarily cross-train.”
This immediately puts patients at a disadvantage. It can be inefficient and inconvenient. More importantly, the patients get care for addiction and the co-occurring condition(s) at separate times. The gold standard is to take care of them at the same time.
Arranging concurrent treatment—especially if the treatment facilities aren’t near each other—isn’t the only obstacle. Often, mental health providers suggest that patients get sober first and then come back to get their other mental health condition(s) treated.
“That isn’t a good idea. Those people often don’t come back,” said McHugh. “They struggle to achieve any extended sobriety, and/or their overall condition worsens because their mood or anxiety disorder isn’t being treated.”
Addressing Stigma in Care
Stigma can also contribute toward patients not getting care for one or more of their mental health conditions.
“It can happen in both directions,” said McHugh. “Substance misuse can often be stigmatized in other psychiatric treatment settings, and in addiction treatment settings, other mental health concerns can be pushed to the back burner. The ability to get integrated care for one person is a huge challenge.”
McHugh stressed that stigma is a significant concern for someone addicted to drugs or alcohol. This makes it even more important for patients to get treatment where the substance use disorder is treated with the same respect and attention as other mental health disorders.
“There are a lot of data showing that people with substance addictions are treated differently,” she said. “If people expect that they will not be treated well if their provider knows they have a substance-related problem, that’s a major barrier.”
Treating Co-Occurring Conditions Together
Aside from helping to ensure that patients get care for all of their conditions, there is another compelling reason to get concurrent and integrated care—complexity.
“The treatment facilities that do this really well are those that treat all of a patient’s conditions at the same time and in the same place, preferably with the same provider or team of providers,” said McHugh. This is ideal “because it’s impossible for us to pull out one disorder, pull out the other one, and treat them as two distinct entities—because they never are. There is a lot of overlap and a lot of intersection between symptoms.”
Co-occurring disorders can also feed off each other. She explained that when the symptoms of one condition improve, the symptoms of the other(s) often worsen.
“For some people, it can almost feel like whack-a-mole. You get one thing under control, and the other pops back up. If someone’s drinking, that can mask the anxiety. But if you stop drinking, the anxiety comes back up. That’s why it’s so hard to treat one and then the other.”
Roads to Recovery
When addressed together there are highly effective evidence-based treatments for co-occurring disorders. Most are forms of cognitive behavior therapy (CBT) or other behavioral therapies, such as dialectical behavior therapy. Mindfulness-based therapies are also becoming more commonplace.
Integrated group therapy (IGT), developed by McLean’s Roger D. Weiss, MD, is one such treatment model with demonstrated success. IGT simultaneously focuses on treating substance use and bipolar disorder. Several randomized clinical trials have shown that this is a highly effective treatment.
Another successful treatment approach is called concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE). This CBT technique combines prolonged exposure therapy for PTSD with relapse prevention for addiction.
Medications are also a part of standard care for co-occurring disorders. This may include medications targeting both the addiction and the other psychiatric disorder, such as combining antidepressant medications with alcohol use disorder medications.
While these and other specialized treatments are effective, McHugh said that developing generalized therapies to treat broader combinations of co-occurring disorders is now a major goal for those in her field.
“When you think of the number of condition pairings out there, the list gets very long,” she said. “There’s a lot of interest in developing transdiagnostic treatments to increase access to effective care.”
Transdiagnostic treatments focus on common features of different disorders, such as difficulty managing negative emotions or impulsiveness. This approach can reduce the training burden for treatment providers. It may also be a better fit for people with co-occurring disorders, who often have more than two conditions.
Addiction Is a Mental Health Disorder
So why aren’t more patients with coexisting disorders being diagnosed and treated in the same place? A big reason may be the failure to recognize substance use disorders as mental illness.
Per the Substance Abuse and Mental Health Services Administration (SAMHSA) website: “The coexistence of both a mental health and a substance use disorder is referred to as co-occurring disorders.” And SAMHSA is far from being the only health care organization to separate mental illness from addiction to drugs or alcohol.
Substance use disorders, however, are considered a mental illness by organizations such as the National Institute on Drug Abuse and the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, also recognizes substance use disorders as a mental illness.
As long as we hold on to outdated perceptions of substance addictions, such as the notion that they are the result of choices and a lack of willpower, patients will continue to be left behind.
“The more that we can get people to consider substance use disorder to be a mental health disorder,” said McHugh, “the better off we’ll all be.”