Co-occurring disorders
Co-occurring disorders (CODs) refer to the simultaneous presence of one or more mental disorders along with substance use disorders, such as alcohol and drug abuse. This condition is characterized by a complex interplay where neither disorder directly causes the other, but they can exacerbate each other’s effects. Individuals diagnosed with a substance abuse disorder are significantly more likely to also have a serious mental illness, and vice versa. Common risk factors for CODs include family history, multidrug use, and socio-economic challenges such as homelessness and limited access to treatment.
Research indicates that a substantial number of adults and adolescents with mental illness engage in substance use as a form of self-medication for their symptoms. Treatment for CODs has evolved to emphasize integrated approaches that address both disorders simultaneously, recognizing their intertwined nature. Effective treatment may involve various strategies, including cognitive behavioral therapy and peer support, tailored to the individual’s unique journey toward recovery. This holistic focus aims to improve the overall quality of life for those experiencing co-occurring disorders.
Subject Terms
Co-occurring disorders
- ALSO KNOWN AS: Chemical abuse and mental illness; comorbid disorder; co-occurring psychiatric and substance disorders; dual diagnosis
DEFINITION: Co-occurring disorders (CODs) refer to diagnoses of one or more mental disorders with the use of alcohol and drugs of abuse. A COD diagnosis applies when one or more of each of the two types of disorders can be established independently of the other. Comorbidity of substance abuse disorders and mental illness is common, although individual conditions may vary in terms of severity, chronicity, disability, and degree of impairment in functioning.
Overview
Persons who have been diagnosed with a substance abuse disorder are twice as likely to also have a serious mental illness, compared with the general population. The reverse also holds true—people diagnosed with a serious mental illness are twice as likely to also have a substance abuse disorder. When two (or more) separate disorders occur simultaneously or concomitantly in the same person, they are said to be comorbid or co-occurring, although one illness does not directly cause the other.
Despite this, the two disorders do interact, and each can affect the course and outcome of the other. Substance abuse disorders and serious mental illnesses are caused by overlapping factors, such as underlying deficits in the brain and genetic vulnerabilities, and both affect similar neurotransmitters and signaling pathways. Substance abuse can exacerbate or trigger psychosis and mood and affective disorders; worsening or untreated mental illness can intensify the drug or alcohol problem.
Experience has shown that mental health issues tend to surface before the onset of substance abuse, which then becomes a conscious or subconscious form of self-medication to alleviate symptoms of mental anguish. People with COD have a poorer prognosis and higher rates of drug relapse, and they are more prone to treatment noncompliance and violent behaviors. Risk factors for having CODs include family history of substance use; multidrug use; antisocial personality disorder; being a young, single, adult male; having a lower level of education; homelessness; incarceration; and limited access to treatment.
Evolving Evidence
The association between substance abuse disorder and serious mental illness has been well established, supported by several major studies first conducted during the late 1990s. These studies include the landmark Epidemiologic Catchment Area Study and the National Comorbidity Survey, both sponsored by the National Institute of Mental Health. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the US Department of Health and Human Services, issues its annual National Survey on Drug Use and Health (NSDUH), which provides data on health and the use of tobacco, alcohol, and illicit drugs in the United States.
According to the NSDUH for 2023, 20.4 million adults aged eighteen years or older had any form of mental illness (AMI) co-occurring with a substance use disorder during the past year, and 6.8 million had a serious mental illness (SMI) co-occurring with substance use disorder. In addition, adults with any past-year mental illness (AMI or SMI) had higher rates of past-year illicit drug use compared to those with no mental illness—42.4 percent of adults with AMI and 51.9 percent with SMI versus 21 percent with no mental illness. Likewise, rates of past-year tobacco use and past-month binge alcohol use were higher among adults with mental illness.
The 2023 NSDUH also reported that the approximately 4.5 million adolescents between the ages of twelve and seventeen who had experienced a major depressive episode (MDE) in the past year had higher rates of past-year illicit drug use compared with those without an MDE (28.4 percent versus 11.6 percent).
Treatment Approaches
Researchers now have a better understanding of the prevalence of CODs, of the specific issues related to CODs, and of how CODs affect treatment and treatment outcome. Of the 20.4 million adults in the US with COD in 2023, 62.4 percent of those with AMI and 75 percent of those with SMI received treatment for either mental illness or substance use at a specialty facility. The majority of both groups received only mental health treatment. However, efforts to provide targeted treatment for both disorders concurrently are gaining favor, as mental health professionals realize the need to address the interrelationships among the two disorders and begin to focus more attention on their shared neurobiological aspects.
Integrated treatment involves combining COD treatment with a primary treatment relationship or service setting. The intention is to treat the whole person. SAMSHA states that integrated COD treatment “is an evidence-based approach to care, which recognizes that individuals go through different stages on their way to recovery.” These stages include engagement (establishing a working alliance), persuasion (forming a trusting relationship), active treatment (seeing the problem and making positive changes), and relapse prevention (creating a relapse prevention plan and building on positive behaviors). Such practices as integrated screening and assessment techniques, treatment planning strategies, motivational interviewing, cognitive behavioral therapy, and peer support are part of the treatment program. Integrated stage-wise treatment is proving to be a viable path to recovery and is helping individuals with COD improve the quality of their lives.
Bibliography
Atkins, Charles. Co-occurring Disorders: Integrated Assessment and Treatment of Substance Use and Mental Disorders. Premier Publishing and Media, 2014.
Choi, Sam, et al. "Gender Differences in Treatment Retention among Individuals with Co-occurring Substance Abuse and Mental Health Disorders." Substance Use and Misuse, vol. 50, no. 5, 2015, pp. 653–63. Academic Search Complete, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=102809260&site=ehost-live. Accessed 3 Oct. 2017.
Galanter, Marc, and Herbert D. Kleber, editors. Psychotherapy for the Treatment of Substance Abuse. American Psychiatric Publishing, 2011.
Hendrickson, Edward L. Designing, Implementing, and Managing Treatment Services for Individuals with Co-occurring Mental Health and Substance Use Disorders: Blueprints for Action. Haworth Press, 2006.
Mignon, Sylvia I. Substance Abuse Treatment: Options, Challenges, and Effectiveness. Springer Publishing, 2015.
Smith, John. Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide. Jason Aronson, 2007.
US Department of Health and Human Services. "Highlights for the 2023 National Survey on Drug Use and Health." Substance Abuse and Mental Health Services Administration, www.samhsa.gov/data/sites/default/files/NSDUH%202023%20Annual%20Release/2023-nsduh-main-highlights.pdf. Accessed 16 Dec. 2024.