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Concurrent Disorders Centre for Addiction
and Mental Health

Concurrent Disorders

 
 

 What are they?

 

​What are concurrent disorders?

Concurrent Substance Use and Mental Health Disorders: An Information Guide
 
A person with a mental health problem has a higher risk of having a substance use problem, just as a person with a substance use problem has an increased chance of having a mental health problem. People who have combined, or concurrent, substance use and mental health problems are said to have concurrent disorders.

 
Concurrent disorders can include combinations such as:
 
  • an anxiety disorder and a drinking problem
  • schizophrenia and cannabis dependence
  • borderline personality disorder and heroin dependence
  • depression and dependence on sleeping pills.

 
 
 
 
Many other concurrent disorders are possible, because there are many types of mental health and substance use problems. A note about language In this information guide, we use the phrases “substance use problem” or “mental health problem” to describe the broad range of situations, from mild to severe, that a person with concurrent disorders may experience. We use the phrases “substance use disorder” or “mental health disorder” only where the text refers to a specific diagnosis.

 
Concurrent disorders are also sometimes called:
 
  • dual disorders
  • dual diagnosis
  • co-occurring substance use and mental health problems.

 
 
 
In Ontario, the term dual diagnosis is used when a person has an intellectual disability and a mental health problem.

 

How common are concurrent disorders?

 
A large American study¹ found the following rates:
 
  • 30 per cent of people diagnosed with a mental health disorder will also have a substance use disorder at some time in their lives. This is close to twice the rate found in people who do not have a lifetime history of a mental health disorder.
  • 37 per cent of people diagnosed with an alcohol disorder will have a mental health disorder at some point in their lives. This is close to twice the rate found in people who do not have a lifetime history of a substance use disorder.
  • 53 per cent of people diagnosed with a substance use disorder (other than alcohol) will also have a mental health disorder at some point in their lives. This is close to four times the rate found in people who do not have a lifetime history of a substance use disorder.

 
 
 
The most common combinations are:
 
  • substance use disorders + anxiety disorders
  • substance use disorders + mood disorders.

 
 

Anxiety disorders

 
In general, 10 to 25 per cent of all people will have an anxiety disorder in their lifetime.
 
Among people who have had an anxiety disorder in their lifetime, 24 per cent will have a substance use disorder in their lifetime.

 

Major depression

 
In general, 15 to 20 per cent of all people will have major depression in their lifetime.
 
Among people who have had major depression in their lifetime, 27 per cent will have a substance use disorder in their lifetime.

 

Bipolar disorder

 
In general, one to two per cent of all people will have bipolar disorder in their lifetime.
 
Among people who have had bipolar disorder in their lifetime, 56 per cent will have a substance use disorder in their lifetime.

 

Schizophrenia

 
In general, one per cent of all people will have schizophrenia in their lifetime.
 
Among people who have had schizophrenia in their lifetime, 47 per cent will have a substance use disorder in their lifetime.

 

When do concurrent disorders begin?

 
Mental health and substance use problems can begin at any time: from childhood to old age. When problems begin early and are severe, recovery will probably take longer, and the person will need to work harder and have more support. On the other hand, if the problem is caught and treated early, the person has a better chance of a quicker and fuller recovery.

 
People often ask, “Which came first: the mental health problem or the substance use problem?” This is a hard question to answer. Often it is more useful to think of them as independent problems that interact with each other.



 
Notes:
 
1. Reiger, D.A., Farmer, M.E. & Rae, D.S. (1990). Co-morbidity of mental disorders with alcohol and other drug abuse, Results from the Epidemiological Catchment Area (ECA) study. Journal of the American Medical Association, 264, 2511–2518.
 

 Symptoms

 

​What are the symptoms of concurrent disorders?

Concurrent Substance Use and Mental Health Disorders: An Information Guide
 
Concurrent disorders is a term for any combination of mental health and substance use problems. There is no one symptom or group of symptoms that is common to all combinations.

 
The combinations of concurrent disorders can be divided into five main groups:
 
  • substance use + mood and anxiety disorders, such as depression or panic disorder
  • substance use + severe and persistent mental health disorders, such as schizophrenia or bipolar disorder
  • substance use + personality disorders, such as borderline personality disorder, or problems related to anger, impulsivity or aggression
  • substance use + eating disorders, such as anorexia nervosa or bulimia.
  • other substance use + mental health disorders, such as gambling and sexual disorders.
 
 
 
 
 

To understand and treat a particular combination, we need to look at the specific problems to see:
 
  • how severe the problems are
  • how the problems affect each other.
 
 

How severe are the problems?

 
Some people with concurrent disorders have very severe problems with both their mental health and their substance use. This makes it hard for them to function day-to-day. While other people may have milder mental health and substance use problems, the impact on their lives can still be difficult.

 
People with concurrent disorders are likely to receive treatment in one of the following settings:
 
  • primary health care; for example, family doctors
  • mental health agencies
  • substance use agencies
  • specialized concurrent disorders treatment programs.
 
 
 
 

The treatment setting often depends on how severe a person’s problems are.ConcurrentDisordersSymptoms.jpg

How does each problem affect the other one?

Mental health problems and substance use problems can affect each other in several ways:
  • Substance use can make mental health problems worse.
  • Substance use can mimic or hide the symptoms of mental health problems.
  • Sometimes people turn to substance use to “relieve” or forget about the symptoms of mental health problems.
  • Some substances can make mental health medications less effective.
  • Using substances can make people forget to take their medications. If this happens, the mental health problems may come back (“relapse”) or get worse.
  • When a person relapses with one problem, it can trigger the symptoms of the other problem.
  • A person with concurrent disorders will often have more serious medical, social and emotional problems than if he or she had only one condition. Treatment may take longer and be more challenging. 

 

 

 Therapies

 

​How are concurrent disorders treated?

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, concurrent substance use and mental health problems are often related, and they affect each other. So clients have the best success when both problems are addressed at the same time, in a co-ordinated way. The treatment approach usually depends on the type and severity of the person’s problems. A person might receive psychosocial treatments (individual or group therapy) or biological treatments (medications), or often both.

Although the overall treatment 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.

Where do people get treatment?

Most people with concurrent disorders have mild to moderate problems that can be treated in the community, through their family doctor, for example. People with severe problems may need specialized care for concurrent disorders.

What is integrated treatment?

Clients with severe concurrent mental health and substance use problems may need integrated treatment. Integrated treatment is a way of making sure that treatment is smooth, co-ordinated and comprehensive for the client. It ensures that the client 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
  • ensure their basic life needs are being met.

Integrated treatment works best if the client has a stable, trusting, long term relationship with one case facilitator. This person is a health care professional, such as a case manager or therapist. Even though one person is responsible for overseeing the client’s treatment, the client may work with a team of professionals, such as psychiatrists, social workers and addiction therapists.

If all the treatment services are not in one location, two or more programs 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:
  1. treat the mental health problems, or
  2. refer clients to a mental health agency, and work with that agency. Therapists at both agencies would keep in touch about the clients’ progress.

Treatment goals

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. Clients who received treatment from both systems may have been confused by the differences. For example:
  • Many addiction services agree that reducing substance use is a realistic goal for clients at the beginning of treatment. This is called harm reduction. As the client moves through treatment, the long-term goal may be abstinence: to stop the use of the substance completely. However, some mental health programs ask clients to completely stop using alcohol or other drugs before they can get treatment.
  • Many mental health problems benefit from treatment with medications. However, some substance use programs may try to help the client stop taking all drugs, including those used to treat mental health problems. Fortunately, staff in many mental health and substance use programs now work more closely together. As a result, clients may see fewer differences like the ones described above.

The ultimate goal of treatment is for clients to:
  1. decide what a healthy future means for them
  2. find ways to live a healthy life.
  3. The treatment plan needs to be customized—this means it will address each client’s particular needs. Both the substance use and the mental health problems will be addressed with the most appropriate approaches from each field.

Types of treatment

Treatment for concurrent disorders includes psychosocial treatments and medication. Clients may receive one or the other, or both.

Psychosocial treatments

Psychosocial treatments are an important part of treatment for concurrent disorders. They include:
psychoeducation
psychotherapy (counselling, individual and group therapy)
family therapy
peer support.

Psychoeducation

Psychoeducation is education about mental health and substance use issues. People who know about their problems are more able to make informed choices. Knowledge can help clients and their families:
  • deal with their problems
  • make plans to prevent problems
  • build a plan to support recovery.

While all people should receive psychoeducation when they begin treatment for concurrent disorders, as they move through recovery, they may benefit more from psychoeducation. For people who have milder problems, psychoeducation alone may be the only treatment they need. Psychoeducation sessions include discussions about:
  • what causes substance use and mental health problems
  • how the problems might be treated
  • how to self-manage the problems (if possible)
  • how to prevent future episodes.

Psychotherapy

Psychotherapy is sometimes called “talk therapy.” It helps people deal
with their problems by looking at how they:
  • think
  • act
  • interact with others.

There are many different types of psychotherapy. Some types are better for certain problems. Psychotherapy can be either short-term or long-term. Short-term therapy has a specific focus and structure. The therapist is active and directs the process. This type of treatment is usually no longer than 10 to 20 sessions.

In long-term therapy, the therapist is generally less active, and the process is less structured. The treatment usually lasts at least one year. The aim is to help the client 
work through deep psychological issues.

Successful therapy depends on a supportive, comfortable relationship with a trusted therapist. The therapist can be a:
  • doctor
  • social worker
  • psychologist
  • other professional.

Therapists are trained in different types of psychotherapy. They may work in hospitals, clinics and private practice.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a type of short-term psychotherapy. CBT works well for a broad range of concurrent disorders.

In CBT, people learn to look at how their beliefs or thoughts affect the way they look at themselves and the world. Some deeply held thoughts have a strong influence on our mood and behaviour. For instance, if we are depressed and drinking too much and think no treatment will help, then we might not seek treatment. CBT helps people identify and change such thoughts and learn new strategies to get along better in everyday life.

Dialectical behaviour therapy

Dialectical behaviour therapy (DBT) is a type of cognitive behavioural therapy. It is used to treat a range of behaviour problems. DBT draws on Western cognitive behaviour techniques and Eastern Zen philosophies. It teaches clients how to:
become more aware of their thoughts and actions
tolerate distress
manage their emotions
improve their relationships with other people.

Insight-oriented or psychodynamic psychotherapies

Insight-oriented or psychodynamic psychotherapies tend to be longerterm and less structured. These therapies reduce distress by helping people understand what makes them act the way they do.

Interpersonal therapy

Interpersonal therapies help clients get better at communicating and interacting with others. These therapies help people:
look at how they interact with others
identify issues and problems in relationships
explore ways to make changes.
Interpersonal group therapy focuses on the interactions among group members.

Group therapy

Group therapy can help people who have concurrent disorders. Group therapy can include treatments such as:
  • cognitive behavioural therapy
  • interpersonal therapy
  • psychoeducation.

A group setting can be a comfortable place to discuss issues such as family relationships, medication side-effects and relapses.

Family therapy

Families may also be involved in the person’s treatment. Support from family members can help the person who has concurrent disorders. Family members may also enter therapy themselves. Therapy for families can offer a range of help. For example:
  • Families can learn about substance use and mental health problems.
  • Family members can enter care as clients themselves.

Family therapy can:
  • teach families about concurrent disorders
  • offer advice and support to family members.

Usually therapists work with one family at a time. Sometimes family therapy is offered in a group setting with other families in similar situations.

Group members can share feelings and experiences with other families who understand and support them.

Peer support group

Peer support groups can be an important part of treatment. A peer support group is a group of people who all have concurrent disorders. These people can accept and understand one another, and can share their struggles in a safe, supportive environment. Group members usually develop a strong bond among themselves. People who have recently been diagnosed with concurrent disorders can benefit from the experiences of others.

There are peer support groups for clients and for families. Groups for clients include Double Trouble groups and Dual Recovery Anonymous. The Family Association for Mental Health Everywhere (FAME) has groups for families. See page 40 for further information. Although these groups are often called self-help, peer support actually offers a type of help called mutual aid.  

Biological Treatments

Medications used to treat mental health problems

Medications may help control symptoms and prevent them from coming back. Psychiatric Drugs Explained, by David Healy, is a useful source of information about how medications work. The main types of medications for mental health problems are:
  • antidepressant medications
  • anti-anxiety medications
  • mood stabilizers
  • antipsychotic medications.

Antidepressant medications

Antidepressant medications are used to treat depression. Some are also helpful for anxiety disorders. More than 40 antidepressants are available.

Examples include:
  • selective serotonin reuptake inhibitors (SSRIs): fluoxetine (e.g., Prozac®), paroxetine (e.g., Paxil®), sertraline (e.g., Zoloft®)
  • tricyclic antidepressants (TCAs): amitriptyline (e.g., Elavil®), nortriptyline (e.g., Aventyl®), imipramine (e.g., Tofranil®), desipramine (e.g., Norpramin®), clomipramine (e.g., Anafranil®)
  • monoamine oxidase inhibitors (MAOIs): tranylcypromine (e.g., Parnate®), phenelzine (e.g., Nardil®), moclobemide (e.g.,Manerix®)
  • others: nefazodone (e.g., Serzone®), venlafaxine (e.g., Effexor®), bupropion (e.g.,Wellbutrin SR®).

Anti-anxiety medications

Anti-anxiety medications are used to treat anxiety. Benzodiazepines are a family of anti-anxiety medications. These drugs are also sometimes used to help people who are going through withdrawal from alcohol. They are mild sedatives (they can cause people to feel relaxed and sleepy).

Benzodiazepines are considered safe to use in the short term. If used for a long time, however, they may cause dependence. For this reason, benzodiazepines are usually prescribed for long-term use only if other medications haven’t worked. If benzodiazepines are prescribed, the dose needs to be carefully watched. Anti-anxiety medications include:
  • chlordiazepoxide (e.g., Librium®)
  • diazepam (e.g.,Valium®)
  • alprazolam (e.g., Xanax®)
  • lorazepam (e.g., Ativan®)
  • buspirone (e.g., Buspar®).

Mood stabilizers

Mood stabilizers are medicines that help reduce mood swings. They also help prevent manic and depressive episodes. The three main types of mood stabilizers are:
  • lithium (e.g., Carbolith®)
  • valproic acid (e.g., Epival®)
  • carbamazepine (e.g., Tegretol®).
  • Antipsychotic medications
  • Antipsychotic medications are used to treat psychosis. Delusions and hallucinations are examples of symptoms of psychosis. There are two main types of antipsychotics:
  • typical: haloperidol (e.g., Haldol®), chlorpromazine (e.g., Largactil®), perphenazine (e.g., Trilafon®)
  • atypical: clozapine (e.g., Clozaril®), risperidone (e.g., Risperdal®), olanzapine (e.g., Zyprexa®).

Medication used to treat substance use problems

Medications can also help treat substance use problems. Some are used in the short-term while others may be needed for longer periods.
There are three main types of medications that help with substance use:
  • aversive medications
  • medications that reduce cravings
  • substitution medications.

Aversive medications

People who take aversive medications will have unpleasant effects if they continue their substance use. An example of an aversive medication is disulfiram (Antabuse®), which is used for alcohol dependence.

Craving reduction

Some medications change the way brain chemicals respond to drugs. They may block the enjoyable effects of a drug, or reduce cravings for the drug. Examples of medications that reduce cravings are:
naltrexone (ReVia®) for alcohol or opioid dependence
bupropion (Wellbutrin®, Zyban®) for nicotine addiction.

Substitution medications

Substitution medications reduce or prevent withdrawal symptoms. They may also reduce or eliminate drug cravings. Combined with medical and social support, these medications can help people leave the lifestyle that revolves around harmful substance use. Methadone, used to treat dependence on opioid drugs such as heroin, is the most common substitution medication.

Compliance and side effects

Medications may have troubling side-effects. Many side-effects lessen with time. If you are having serious side-effects, talk to your doctor. The doctor can change the dose or prescribe other medications to reduce or avoid side effects. Remember, too, that substance use may interfere with the positive effects of medications.

A doctor will monitor your use of medication. In some cases, the doctor may check the amount of medication in your blood. This allows you to receive the correct dose. The doctor may also check some body organs to see how they are affected by medication.
With the proper precautions, the risk of serious complications from medications is usually lower than the risks of living with untreated substance use and/or mental health problems.

Special treatment situations

During their recovery, people may need specific interventions, such as:
withdrawal management
crisis management
relapse prevention
hospitalization.

Withdrawal management

People sometimes need short-term help with withdrawal from substance use. Withdrawal management helps them manage symptoms that happen when they stop using the substance. Withdrawal management helps prepare clients for long-term treatment. Clients also learn about substance use and treatment options.

There are three types of withdrawal management:
In community withdrawal management, the person goes through withdrawal at home. Health care professionals help support and guide the person through this.
A person may stay in a withdrawal management centre. This is a special facility where the person receives more intensive care and supervision.

Medical withdrawal management may be needed if a client has severe withdrawal symptoms, such as seizures or hallucinations. A doctor and nurse supervise the withdrawal. The client may stay in hospital or visit as an outpatient. The client may receive medications to replace the drug or ease symptoms.

Crisis Management

There may be times when people who have concurrent disorders are in crisis. For example, the person may be in danger of hurting himself or herself, or other people.
It can be very hard for family members to cope effectively with a sudden crisis. It is useful to plan some emergency strategies when the person is well. This allows everyone to be prepared if anything does happen.
Depending on the situation, a crisis may be managed at home with family, peer and professional support. Sometimes, the person may need to be hospitalized as a result of a crisis.

After the crisis has passed, the person may need a change in the treatment approach. The person may need to return to therapy if he or she has finished treatment.

Relapse prevention
In their most severe forms, mental health and substance use problems are chronic and recurring. This means that, even after a person has received treatment, the problems may come back, or relapse.

Relapse is part of the recovery process. A relapse is not a reason to stop treatment. If the person is taking medications for a mental health problem, he or she needs to keep taking them.

It is important to acknowledge and discuss the relapse. Relapse can be used as:
  • a chance to learn
  • a chance to review the treatment plan
  • a chance to renew a plan of action.

People who have had a relapse of substance use or mental health problems may not need intensive medical care. The relapse may be handled through individual therapy or in a group setting.

Hospitalization

During a severe crisis or relapse, some people may need to be in the hospital. This may be when clients are at risk of serious consequences, due to:
  • aggressive behaviour
  • taking dangerous risks
  • overdosing
  • self-harming or suicidal behaviour
  • failing to look after their own basic needs.

In such cases, the person may stay in the hospital from a few days up to a few weeks. In hospital, the person may attend group or individual therapy sessions each day. Clients should expect to leave hospital when:
  • follow-up arrangements are in place
  • symptoms have improved
  • they are able to function safely and care for themselves at home.
  • Voluntary versus involuntary admissions
  • People are usually admitted to hospital voluntarily. This means that they
  • agreed to enter the hospital
  • are free to leave hospital at any time.

However, in most places, the law also allows any doctor to admit a person to hospital involuntarily. This means the person may not agree that he or she needs help, and does not want to be in the hospital. This can happen if the doctor believes there is a serious risk that:
  • the person will physically harm himself or herself
  • the person will physically harm someone else.

Each province, state or jurisdiction has its own process for admitting people to hospital involuntarily. For example, in Ontario, if the person doesn’t have a doctor, families may ask a justice of the peace to order an examination by a physician. In the examination, the physician will decide if the person needs to be assessed in a hospital with a psychiatric facility. The physician must be able to prove that the person’s illness represents a risk of harm.

Laws protect the rights of people who are admitted involuntarily. For instance, a “rights advisor” will visit. The rights advisor will ensure that the client has the chance to appeal the involuntary status before an independent board of lawyers, doctors and laypeople.
The police are sometimes needed to help to get a person to hospital. Family members may agonize over whether to involve the police. They often feel very guilty about calling the police, even if the police are needed to protect the person’s life. Remember, when people threaten suicide, they are usually pleading for help. They are taken seriously. Suicidal thinking is often a temporary feeling.When a person feels suicidal, he or she needs to be kept safe.
 

 Finding Treatment

 

​Treatment and support:


Ontario Mental Health Helpline (open 24/7 for treatment anywhere in Ontario)​​
 

 Resources

 
 

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