Research by the Pew Charitable Trusts last year revealed that one in nine Americans with co-occurring disorders were arrested every year between 2017 and 2019. While the figure is nowhere close to 85% of offenders not diagnosed with substance use disorder (SUD) or any mental health condition, such a trend continues to set a dangerous precedent. (1)
The study pointed out that all but 10% of those diagnosed with co-occurring disorders who are incarcerated don’t get treated. This disorder is hard to treat and, without professional intervention, can worsen to the point of contemplating more dangerous thoughts and even resume substance abuse once the person re-enters society—if they do at all. (1)
With this study also highlighting that such scenarios barely get widespread attention, now is a good time to discuss co-occurring disorders and the recovery pathways available to the afflicted. These people need more help than you might think.
Co-Occurring Disorders Explained
As defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR being the latest version), co-occurring disorders mean that an individual is suffering from a pair of disorders simultaneously. These are typically SUD and an associated mental disorder and can be more than two and/or in any combination.
Most Common Mental Disorders | Most Common Misused Substances |
Anxiety and mood disorders | Alcohol |
Attention deficit hyperactivity disorder | Hallucinogens |
Bipolar disorder | Marijuana |
Conduct disorders | Opioids/painkillers |
Major depressive disorder | Prescription drugs |
Post-traumatic stress disorder | Stimulants |
Schizophrenia | Tobacco |
Source: Substance Abuse and Mental Health Services Administration (SAMHSA)
Co-occurring disorders also go by another name: dual diagnosis. In 2022, SAMHSA logged a total of 21.5 million Americans diagnosed with this condition or 6.5% of the population at the time. Yet, however small the number, experts can’t stress enough how dangerous this condition is if left untreated for too long. (2)
For starters, as if one mental health condition isn’t challenging enough to manage, two is double the difficulty. Symptoms vary by mental disorder and type of substance misused, but according to the American Psychiatric Association (APA), warning signs may include:
- Drastic changes in eating and sleeping habits
- Dramatic mood swings (e.g., sadness to anger on a whim)
- Loss of interest in activities that the person used to enjoy
- Difficulty thinking straight and focusing on activities
- Sense of disconnection from one’s surroundings or reality
- Increased absenteeism at work or school
- Distancing themselves from family and friends
- Exhibiting uncharacteristic or illogical behavior
A common misconception is that mental health conditions can be treated the same way as physical illnesses like the flu or injuries. The problem is that the symptoms of the latter can manifest as pointing to a genuine disorder or a fleeting feeling. For instance, a mood swing can be a symptom of anxiety disorder or an effect of missing breakfast this morning.
The APA also stressed that a few symptoms on the list aren’t enough to be diagnosed with a mental health condition, let alone co-occurring disorders, though it’s enough to warrant an evaluation. Symptoms that greatly affect the person’s daily routines should be enough to necessitate a visit to the doctor. Entertaining thoughts of self-harm or, worse, suicide is a sign that they need professional help fast.
Online references such as jacksonhouserehab.com should have information on potential signs of co-occurring disorders. If you’re unsure if your afflicted loved one is suffering from co-occurring disorders, asking a professional won’t hurt.
The Various Roads to Recovery
Treating co-occurring disorders entails dealing with the patient’s SUD. Without addressing the root of the problem, the misused substance’s effects will continue to negatively affect their mental state, and any mental disorder might persist or recur.
SAMHSA recognizes four treatment models under the Substance Use Disorder Treatment for Persons with Co-Occurring Disorders: A Treatment Improvement Protocol (the latest being TIP-42). Here’s a breakdown of each. (3)
Integrated Care
Sometimes called collaborative care, integrated care is widely considered a best practice for treating patients with co-occurring disorders. This approach involves bringing together behavioral and medical care to design a comprehensive program that addresses the patient’s general health needs.
Think of this as being treated for SUD and also for any chronic illness brought about by it. That said, it isn’t unusual for treatments for mental disorders to include meds like antidepressants, mood stabilizers, and antipsychotics. Other examples include the use of dual recovery skills and group interventions for triple diagnosis.
Multiple studies in the past decade have credited the integrated care model with a wealth of benefits, from reduced substance use to improved quality of life. It’s also versatile and able to deliver effective treatment in various settings, including in jails and among homeless populations.
Assertive Community Treatment (ACT)
First developed by a pair of professors from the University of Wisconsin Madison in the 1970s, ACT is a more intensive and long-term treatment program for individuals with serious mental illness. Over time, and with a few tweaks to the original model, researchers realized its potential in managing co-occurring disorders.
As the term implies, this model requires care providers to actively engage patients and deliver intensive services. Given that they typically provide care to people with serious mental illness, they can also assist with the patient’s needs at home, from helping around their house to getting them to where they need to go.
In a way, you can consider this a more personalized care approach, as it relies on establishing a close relationship with the patient. However, it also requires the care provider to deliver 24/7 emergency care, which can be taxing on them. This is why TIP-42 recommends care providers only manage around ten patients at a time.
As such, ACT is reserved for those diagnosed with co-occurring disorders and suffer most severely from their symptoms. The list of mental health conditions that count as serious mental illness is relatively long, but common ones include:
- Severe bipolar disorder
- Severe, major depression
- Schizophrenia
Essentially, any condition with the word “severe” tacked in it can be ideal for ACT. That makes such treatment programs rare, as only an estimated 5% of Americans have serious mental illness. Of this group, a smaller number of people suffer from co-occurring disorders. (4)
Integrated Case Management (ICM)
Up until the 1980s, case management primarily entailed referring patients to care providers who were better equipped and trained to handle specific cases. Later, it was replaced with the more efficient ICM model, which combines the so-called “broker model” with the engagement of ACT.
In other words, the care provider is responsible for assisting patients with whatever they need in their daily lives while ensuring that they receive seamless community-based support from intensive services. The services in ICM are less intense than in ACT but are much easier to deliver.
Still, TIP-42 recommends care providers adopting this model to keep the number of managed patients low to be able to deliver more intensive services. Unlike ACT, this model is ideal for a broader range. Anyone who still struggles to recover via ordinary treatment methods can be suitable for treatment via ICM.
Mutual Support and Peer-Based Programs
Lastly, this model focuses on the peer aspect of mental health recovery, with peers providing most of the support. It’s recently gained recognition from mental health advocacies, not just because it’s effective in managing conditions like co-occurring disorders but also it contributes to public awareness on mental health.
TIP-42 refers to this approach as dual recovery mutual-support programs, and two key milestones made this possible. The first is the inception of the 12-step program in the 1930s by the founders of Alcoholics Anonymous (AA). As it implies, it’s made to manage alcoholism through peer support.
The second is the rise of the consumer mental health movement, commonly known as the psychiatric survivors movement. An offshoot of the civil rights movement of the late 1960s, this movement advocated self-determination in getting the mental health support the individual needs. It rallied around the slogan: “Mad Pride.”
Essentially, dual recovery mutual support programs involve being surrounded by fellows suffering from disorders and sharing their stories. A familiar example is a conventional AA meeting, typically led by a chair who has had extensive progress in getting sober and attended by first-time and regular attendees.
However, unlike the other models, this model doesn’t provide clinical or counseling intervention. It relies on fellows helping each other weather this major storm of their lives, as well as encouraging others who have yet to seek help do so.
Which Works Best?
All the models explained here have proven their worth in treating people with mental health conditions and are in use to an extent. When it comes to treating co-occurring disorders, at least for some approaches, the jury is still out.
For example, many studies with positive conclusions for ACT and ICM are filled with flaws like too small sample sizes. Meanwhile, the ones that meet the criteria for valid research generated mixed results. In some studies, both ACT and ICM performed no better than one another in improving the quality of life of people with co-occurring disorders. (3)
This doesn’t mean that these models aren’t worth considering. According to TIP-42, ACT has shown to be effective in treating co-occurring disorders when used with a treatment program for specific substance use. Meanwhile, ICM is reportedly effective among certain groups such as veterans and individuals in conflict with the law.
As mentioned earlier, integrated care is a highly proven practice for managing co-occurring disorders among a broader range of patients. Evidence cited in TIP-42 shows that such an approach has linked to the following:
- Decreased substance use and abstinence
- Improved mental functioning
- Lower rate of hospital visits and hospitalizations
- Increased overall life satisfaction
- Higher rate of patient satisfaction (3)
Dual recovery mutual-support programs have perhaps shown the most potential among the other recovery pathways. Despite the absence of clinical intervention, evidence cited in TIP-42 reveals that the model has been attributed with the following:
- Peace of mind for having a safe space for sharing experiences
- Building a sense of camaraderie and community among fellows
- Building a sense of hope that they’ll fully recover someday
- Education in skills that can contribute to full recovery
- Better awareness about mental health and SUD (3)
As far as other models go, a growing number of their adopters are integrating peer support into their treatment strategies for co-occurring disorders. Given that the models struggle with mixed results from current research, peer support can help them gauge how effective their modes of treatment really are.
As unsatisfactory as the answer may feel, the most effective recovery pathway depends on the individual. It’s up to the care provider to develop a plan that can best satisfy a patient’s needs, whether sticking to one model or using a combination of several.
Taking Care of Oneself
Regardless of the approach, recovery from co-occurring disorders—or any mental health condition for that matter—still necessitates self-care. It seems simple, yet many people neglect this crucial facet of promoting mental wellbeing.
In a Hologic-Gallup survey conducted last April, of the 63% of American women who have difficulties prioritizing their overall health, three out of five said their mental and emotional state gets in the way. On the other hand, social stigma prevents men from seeking help, let alone opening up, leading to being four times more at risk of committing suicide. (5)(6)
A few minutes of unwinding in between routines can make a difference. While it might not look like it’ll do anything, good habits like getting enough sleep and engaging in meaningful pastimes can reduce the risk of certain mental illnesses recurring or getting worse outside of evidence-based care.
Conclusion
Co-occurring disorders may be complicated but not impossible to treat. Modern science has provided several means from which anyone diagnosed with it can become healthy in body and mind again. All it takes are expert insight and, perhaps more importantly, a sense of self-worth.
References:
- More Than 1 in 9 Adults With Co-Occurring Mental Illness and Substance Use Disorders Are Arrested Annually [Internet]. pew.org. Available from: https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2023/02/over-1-in-9-people-with-co-occurring-mental-illness-and-substance-use-disorders-arrested-annually
- Co-Occurring Disorders and Other Health Conditions [Internet]. Samhsa.gov. 2024 [cited 2024 Sep 9]. Available from: https://samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/co-occurring-disorders
- Chapter 7—Treatment Models and Settings for People With Co-Occurring Disorders [Internet]. www.ncbi.nlm.nih.gov. Substance Abuse and Mental Health Services Administration (US); 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK571024/
- SAMHSA. Mental Health Myths and Facts [Internet]. www.samhsa.gov. SAMHSA; 2023. Available from: https://www.samhsa.gov/mental-health/myths-and-facts
- Inc G. Majority of U.S. Women Struggle to Prioritize Health [Internet]. Gallup.com. 2024. Available from: https://news.gallup.com/poll/646529/majority-women-struggle-prioritize-health.aspx
- National Institute of Mental Health. Suicide [Internet]. www.nimh.nih.gov. National Institute of Mental Health; 2023. Available from: https://www.nimh.nih.gov/health/statistics/suicide
