For decades, we have talked about substance use and mental health conditions as “co-occurring.” We have incorporated it into our language, for example, saying that a person “needs a co-occurring program.” Sometimes the term takes on a life of its own, prompting providers to view treatment of co-occurring disorders as an unduly burdensome undertaking that requires its own specialty. Some providers decline to treat people with co-occurring disorders, until one of the disorders has been addressed. This is a mistake.
All programs must treat co-occurring disorders; it cannot be avoided. Studies have found that up to 60 percent of people in substance use disorder programs and 40 percent in mental health settings have a co-occurring disorder. It is simply not possible to effectively treat a person without addressing both disorders in a single, integrated plan.
Mental health disorder impacts a broad range of emotional, cognitive and behavioral functioning, and ranges from mild impairment, to serious problems that can significantly impinge on all areas of a person’s life. Similarly, substance use disorders span a range of substances, patterns of use, severity and impact on life. The interaction of these disorders is often meaningful and critical to identifying an effective treatment.
There remain many misconceptions about prescribing medication and providing psychosocial interventions. Despite the consensus among experts that integrated care should be the standard, providers continue to deny treatment to people who are perceived to have instability in substance use disorder or mental health symptoms, when a co-occurring disorder is present. For example, I have heard about clients, who are experiencing hallucinations and disorganized thoughts and using alcohol and cannabis, having difficulty accessing medication for any conditions, because providers are concerned of the risk, or lack the skills to assess or treat the clients. All treatment providers should be prepared to address the full range of a patient’s conditions, even if the patient is not fully ready to address them all.
Mental health and substance use disorders have similar etiology, and co-occurring disorders are often interconnected. A 2003 survey by Kaiser Permanente surveyed 26,000 people for Adverse Childhood Experience and found a high correlation between those experiences and substance use disorder. This mirrors similar finding for adult mental health disorders.
It is well known that early trauma impacts the brain in the areas of the hippocampus (memory) amygdala (arousal) and limbic system (emotion). These areas of the brain are also involved in anxiety, mood and substance use disorder. They also share common treatment approaches, including cognitive behavioral therapy, dialectical and behavioral therapy, motivational interviewing and family approaches to treatment.
Putting the principles of integrated care into practice can be challenging for programs. It is important that all staff are trained and feel confident in identifying both mental health and substance use disorders. Most programs have implemented a validated screening tool to identify people who have a high likelihood of having a mental health or substance use disorder. Once a person has screened positive, it is important to complete a comprehensive assessment. Co-occurring disorders are not monolithic. Someone at a substance use disorder clinic who has screened positive for a mood disorder will likely have a different symptom pattern than someone with a serious bi-polar disorder who screens positive for a likely substance use disorder at a mental health clinic. A comprehensive assessment should identify specific symptoms, history, remissions and exacerbations, successful strategies, and toxicology testing. The assessment should also include information from personal contacts such as family members.
Many people who experience both mental health and substance use disorders feel discouraged and overwhelmed. It is especially important for providers to convey confidence and hopefulness, to identify individual strengths and develop a plan using the patient’s own voice. It is also important to identify periods of remission and strategies the patient has used successfully in the past.
Clinical staff can also feel overwhelmed when a person seeking treatment presents a complex history or symptom pattern. This is true for co-occurring physical health problems too. Imagine if you or a family member suffered from high blood pressure, obstructive pulmonary disease and early signs of Parkinson’s disease. The most helpful message from a practitioner would be that “you have come to the right place.” Of course, the practitioner would likely need to reach out to specialists for help with the person’s care. However, imagine how discouraging it would be if the practitioner said the person’s needs were too complex, that he or she needed to get one condition under control in order to treat the others, or were sent away with a referral card to another program.
If you work in or operate a program, you may be familiar with and even understand these messages. It can be daunting to think ahead about how to make sure a person gets good care, from the initial assessment through treatment, delivered by experienced and competent staff working within their scope of practice. There may be a need for multiple staff with individual expertise working as a team.
To successfully deliver integrated care, I would suggest that programs start from a strength-based approach. If you have been operating for a while, you have seen many individuals who have co-occurring disorders. Ask yourself which patients have done well and what about their treatment went well. After answering these questions, challenge yourself and your team. What resources would you need to adequately respond to the needs of everyone who sought out your program? Are there agencies in your community who would make good partners in providing integrated care?
Through the work of the New York State Medicaid Redesign Team, there have been many opportunities for providers to partner on seamless, cohesive integrated care. Whether you are pursuing an integrated license, partnering with a behavioral health collaborative, or working within a performing provider system, these opportunities can help solve some of the challenges to integration.
The time has come for all of us to recognize that co-occurring disorders are a normal presentation. They should be anticipated and met with compassion and effective treatment options. There is no reason to wait for all the answers. The consensus was reached a long time ago: we all provide care for co-occurring disorders. It is not possible to do otherwise.