The term 'concurrent disorder' describes a condition in which a person has both a mental health and a substance use problem. This term is quite general and refers to a wide range of presenting issues, needs and problems. For example, someone with schizophrenia who abuses cannabis is considered to have a concurrent disorder, as is an individual who suffers from chronic depression and is also alcohol dependent.
Other combinations constituting a Concurrent Disorder can include someone who has:
Concurrent disorders is the term used in Canada to refer to any co-occurring mental health and substance use disorders, however informally, there are often thought to be two general categories of concurrent disorders that are grouped in relation to how serious the symptoms are. The first group is what we traditionally know as 'concurrent disorders', and refers to the presence of any mental health issue (e.g. mild anxiety) and any substance use concern (e.g. binge drinking on weekends), as long as they occur together. In common practice, this is the group of clients most front-line workers would expect to see as even relatively mild versions of both mental health and substance use issues can cause a great deal of subjective distress and interpersonal difficulty for the person.
The second category is what's loosely referred to by professionals as 'very concurrent disorders' and identifies those individuals whose mental health and substance use symptoms meet more formal diagnostic criteria (in Canada, this would be clients who have at least one mental health and one substance use disorder as defined by the Diagnostic and Statistical Manual- IV, or DSM-IV). This category may represent clients who have for example Bi-Polar Disorder and Alcohol Abuse, or Major Depressive Disorder and Opiate Dependence.
back to top [7]
A person who has a mental health problem has a good chance of having a substance use problem as well. Similarly, a person with a substance use problem has an greater likelihood of having a mental health problem than if they had no addiction issues to start with; in short, if you have one issue (say depression), you are very likely to also have some form of the other issue (say an alcohol problem). In fact, the more we learn about both disorders, the more we come to expect that substance use and mental health issues will occur together in many cases. Given this, it should not be a surprise to the client or their worker to find that for someone who comes for help with one 'problem' (for example their oxycodone use), might very well also find that they also have an underlying mental health issue (perhaps anxiety) that they or their previous workers never really recognized before.
However, while it is known conclusively that people with mental illness have much higher rates of addiction than people in the general population and that similarly, individuals with an addiction have much higher rates of mental illness than people in the general population, it is challenging to determine conclusively how many people have a concurrent disorder because the different studies that have been done have examined different populations and have used differing screening tools to reach their conclusions. Further, people with concurrent disorders are frequently misidentified, as diagnosis can be more difficult because one disorder can mimic another. This is why, depending on the setting studied, prevalence rates for concurrent disorders have been found to range from 20 to 80 percent (Centre for Addiction and Mental Health, "People with Concurrent Disorders," in Virtual Resource for the Addiction Treatment System, Section 3: Special Populations).
For example, one national survey completed in the United States reveals that:
According to the Concurrent Disorders Ontario Network, substance use disorders affect:
In addition, relapse rates for substance use are higher for people with a concurrent mental disorder, as are the chances that symptoms of mental illness will return for those with a concurrent substance use problem.
back to top [7]
There are a number of reasons why substance use and mental health issues occur together in one individual, and often the underlying processes are very similar. Mental health and substance use problems often follow the same onset, course, and prognostic patterns. Some of the features that are common in both kinds of disorders include:
back to top [7]
While mental health and substance use problems have some common characteristics and can be quite similar in terms of their causes, course, and outcomes, how the relationship between the two kinds of issues is actually played out can be extremely complex. There are a huge number of ways in which the two 'problems' can interact, leading to almost endless number of symptoms, behaviours, and presentations. It all depends on what the exact variables are that the person brings to the table, such as their age, gender, socioeconomic situation, supports, diagnoses (and severity of such), set of life experiences including exposure to trauma, and of course all the intrapersonal determinants such as personality factors, motivation to change, and past treatment experiences.
By way of example, let's look at how a person's mental health can interact with and impact their substance use. Mental health problems can act as risk factors for substance use problems. For example, depressive symptoms could lead someone to self-medicate with alcohol for temporary relief from symptoms of depression or the side-effects of the medications they must take to manage their depression. Or, it could be that someone with an anxiety disorder or depression has trouble sleeping and is given tranquilizers which can then be misused or abused.
A person's substance use can also interact with and impact their mental health. Substance misuse may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process. For example, psychiatric symptoms may be covered up or masked by drug or alcohol use. Alternatively, alcohol or drug use or withdrawal from drugs or alcohol can mimic or give the appearance of some psychiatric illnesses. Substance misuse can also act as risk factors for mental illness. For example, struggling with an addiction and its consequences affects your mental health: your moods, behaviours, perceptions, coping strategies and social networks.
Listed below are different ways that substance use and mental health problems can affect each other:
There are also common risk factors that make people vulnerable to developing either substance use or mental health problems, or both: poverty or unstable income, difficulties at school, unemployment or problems at work; isolation; lack of decent housing; family problems; family histories; past trauma or abuse; discrimination; and even biological or genetic factors. And like other people, a person with concurrent disorders may use drugs and alcohol to cope with boredom, depression or anxiety and to increase opportunities for social contact.
We know that the effects of one disorder may compound the effects of the other, thus exacerbating symptoms and making the person's life more challenging. This in turn may then put the individual at risk for other problems such as losing his or her housing, job and perhaps social support networks. The person may also be at risk for medical problems such as HIV/AIDS, hepatitis C, diabetes and respiratory problems. The interplay is complex and if a person has both kinds of problems, the clinical picture can often be murky. However, without appropriate treatment, everything can worsen, leaving people at greater risk of:
back to top [7]
The prevalence numbers cited earlier indicate that regardless of whether one works at a substance use agency or a mental health service, the chances are high that any person walking through the door seeking services will have both mental health and substance use problems. In fact, the general rule now is that the presence of concurrent disorders is an "expectation, not the exception" - that is, people who present to either kind of service are more likely than not to have a concurrent disorder. Given this, anyone working in a mental health, addiction, health or social service agency should have a so-called 'high index of suspicion' when screening their clients for concurrent disorders and be over- versus under-inclusive so that people with both kinds of need are less likely to be missed and fall through the cracks of the system.
A person is diagnosed with a concurrent disorder when they are recognized as having both a mental health problem and a substance abuse problem. For example, someone with major depression who also abuses alcohol has a concurrent disorder, as does someone with schizophrenia who abuses cannabis. A person with concurrent disorder can have more than one mental health problem (schizophrenia and depression) and/or more than one substance abuse problem (cocaine and marijuana) - among other problems or needs.
In today's mental health and addiction treatment and support system, people who have concurrent disorders often have to go to one service for mental health treatment and another place for addiction treatment. Sometimes the services are not connected at all, however since concurrent substance use and mental health problems are often related, and they affect each other, clients have the best success when both problems are addressed at the same time. The goal however, is to have a 'no wrong door' policy whereby no matter where a person finds himself or herself first seeking services and support (i.e., whether this be a mental health or substance use agency, hospital or community setting, or broader health or social services organization), he or she will always receive the service(s) he or she needs, whether this be through the organization approached by the person, or through the supportive connection of the person to somewhere more appropriate for their needs. Wherever the person with co-occurring mental health and substance use problems appears in the system of care, it should ideally always be considered the right place for them to access the services they need from the system.
The treatment approach that professionals use with someone who has a concurrent disorder usually depends on the type and severity of the person's problems. How a person's concurrent disorder is treated will very much depend on what his or her particular 'drug of choice' is, as well as what his or her precise mental health diagnosis and symptoms are. As described earlier, concurrent disorders can include a large variety of combined symptoms. Just a few might be:
Today there are a number of treatment options for concurrent disorders. A person might participate in psychosocial treatments (individual or group therapy), biological treatments (medications), education and psycho-education, or often all three.
There are also a number of different counseling styles and approaches that your worker may use. Some of these may include:
Which exact counseling 'modality' a worker will use may depend on their training or experience, or may be what they've determined would best suit a person's particular needs. It is wise for a person seeking help to devote some time to discussing what counseling style their workers employ as ideally the workers will have knowledge of many different therapies and will be able to use relevant strategies from each of the available models to address the person's concurrent disorders issues. For example, if someone has an anxiety disorder, cognitive behavioural therapy (CBT) is useful as it helps the person to understand and recognize how often symptoms are a result of mistaken thinking patterns - if the person can learn to adjust their "automatic thoughts" then many of the person's symptoms could disappear. Likewise, if the same client is struggling with alcohol misuse, a counselor may want to use some relapse prevention strategies to help the person avoid high-risk using situations and work on making lifestyle changes that are more conducive to staying substance-free.
The above describes what sorts of counseling styles a worker may use when they see a person on a one-on-one, or individual, basis. Often, however, people also decide to join concurrent disorder groups which are very effective treatment options and complement individual counseling. So called 'self-help', or peer-led, groups are also very important once a person has completed residential treatment as they are places to go to get support from peers as well as a chance to learn new skills from non-drug using peers, or a place to practice skills one may have earned while in an addictions program.
It is also now believed that the "gold standard" in mental health and substance use treatment and support is that both are integrated at the level of the client - that is, the person experiences the mental health and substance use treatment and support that he or she receives as being coordinated and appropriate to his or her level of need and readiness to change in relation to each of his or her needs. Clients with severe concurrent mental health and substance use problems also need integrated treatment, although this integration usually needs to take place not only at the level of the client, but also in terms of how the services are actually being delivered (for example, through the provision of services delivered by teams staffed by people with both mental health and substance use training and enhanced concurrent disorders expertise).
Integrated treatment and support is a way of making sure that treatment is smooth, coordinated and comprehensive for the person. It ensures that the person receives help not only with the concurrent disorders, but also in other life areas, such as housing and employment. Ongoing support in these life areas helps clients to maintain treatment successes, prevent relapses, and ensure their basic life needs are being met.
Integrated treatment and support works best if the person with the concurrent disorder has a stable, trusting, long term relationship with at least one consistent person. This person is usually a health care professional, such as a case manager or therapist. Even though this one person is responsible for overseeing the individual's treatment, the individual may work with a team of professionals, such as psychiatrists, social workers and addiction therapists.
If all the treatment and support services are not offered through the same organization, two or more organizations may work together to co-ordinate treatment. For example, a therapist in an addiction program might ask new clients questions to see if they also have mental health problems. If the clients do, the addiction program could either treat the mental health problems, or refer clients to a mental health agency, and work with that agency. Therapists at both agencies would keep in touch about the individual's progress.
Although the overall treatment and support plan should consider both mental health and substance use problems, it is sometimes best to treat one problem first. For example, most people who have concurrent mood and alcohol disorders are likely to recover better if the alcohol disorder is treated first. As another example, a person who is being treated for concurrent problems may have an episode in which the mental health problem gets worse. Treatment might at that point focus on the mental health problem, rather than on the substance use. Treatment and support are still integrated, but the delivery of each kind of service is timed to best match the person's individual needs at the given point in time.
It is important to note that in the past, addiction and mental health treatment services have each had different ways of treating problems. They have also had different ways of thinking about problems. People who received treatment from both systems may have been confused by the differences. For example:
Fortunately however, staff in many mental health and substance use programs now work more closely together. As a result, people may see fewer differences like the ones described above. Ultimately, the goal of treatment is for people to:
The treatment and support plan therefore needs to be customized - doing so means that it will address each individual's specific and unique needs. Both the substance use and the mental health problems will be addressed with the most appropriate approaches from each field.
back to top [7]
To many people, mental illness and substance abuse are frightening. Having just one of these disorders can feel unmanageable. Having multiple issues with which to contend can quickly make people feel overwhelmed and despondent - they are now dealing with two separate sets of responses from people according to their dual issues of mental ill-health and substance use. They may feel self-stigmatizing emotions like guilt and shame, and they are part of societal systems that can be very critical of both disorders. Unfortunately, the fear this can produce can discourage people from seeking help early, a reality that can put them at increased risk of developing complications and put their lives in jeopardy.
Much of the fear surrounding mental illness and substance use problems are based on myths and misunderstandings and tend to be exaggerated. Concurrent disorders need not be feared; like other bio-psycho-social conditions it can be treated - and people can and do recover.
Education about concurrent disorders is one of the best ways to deal with stigma. Demystifying the term concurrent disorder and breaking down what one's actual issues are, finding one's strengths, and developing the right support networks based on this, are all vital to a person overcoming stigma. Believing that recovery is possible, finding appropriate supports and figuring out one's unique set of symptoms and needs with the help of professionals, can not only reduce some of the fear associated with these disorders, but can also promote recovery by helping people anticipate and prepare for what to expect from treatment and from themselves. It is important to always keep in mind that with the right support and intervention concurrent disorders can be very manageable and many people who experience these challenges can expect to lead full and meaningful lives.
back to top [7]
Links:
[1] http://centralwestcdn.ca/about-concurrent-disorders#A
[2] http://centralwestcdn.ca/about-concurrent-disorders#B
[3] http://centralwestcdn.ca/about-concurrent-disorders#C
[4] http://centralwestcdn.ca/about-concurrent-disorders#D
[5] http://centralwestcdn.ca/about-concurrent-disorders#E
[6] http://centralwestcdn.ca/about-concurrent-disorders#F
[7] http://centralwestcdn.ca/about-concurrent-disorders#nav
[8] http://centralwestcdn.ca/sites/default/files/images/face_about_cd_3.jpg
