20 The Gap in Care Between Substance Use Disorder and Mental Health Treatment

Introduction

Coexisting mental health disorders and substance use disorders (SUD) are referred to as a co-occurring disorders . People with existing mental health disorders are more likely to develop substance use disorders compared to those without mental illness. In 2021, it was determined that around 9.2 million adults in the US have a co-occurring disorder (SAMHSA, 2023). Some common mental disorders among individuals in SUD treatment are anxiety and mood disorders, bipolar disorder, major depressive disorder, schizophrenia, post-traumatic stress disorder, and conduct disorders (SAMHSA, 2023). Commonly misused substances in SUD are stimulants, alcohol, marijuana, tobacco, prescription drugs, and hallucinogens.

The Connection Between Substance Use Disorder and Mental Health Disorders

SUD and mental disorders commonly co-occur (NIMH, 2021). However, despite the risk of co-occurrence, one does not necessarily cause the other. Currently, research has three theories as to why SUD and mental disorders co-occur. Common risk factors can contribute to both SUD and mental disorders (NIMH, 2021). Genetics may be a risk factor for SUD and mental disorders in some people. Experiencing stress or trauma can cause genetic changes, which can be passed down from parent to child. Mental disorders can contribute to using substances and substance abuse (NIMH, 2021). Studies have found that people with mental disorders may use substances as a form of self-medication. Temporarily, some drugs may alleviate symptoms. However, over time, substance use can worsen symptoms of mental disorders. Additionally, the brain changes in individuals with mental disorders. These changes can enhance the rewarding effects of substances, increasing the likelihood of continued use. Substance use and abuse can contribute to the development of other mental disorders (NIMH, 2021). Substance use can trigger changes in brain structure and function. These changes to the brain can make a person more susceptible to developing a mental disorder.

Gaps in Offered Treatment

Despite the connection between SUD and mental health disorders, most treatment options fail to address both. Only 6% of adults with concurrent SUD and mental health disorders in the US receive care for both disorders (Zisman-Ilani et al., 2023, pp. 201–203). Treatment for SUD and mental health disorders remain separate. Primary care physicians typically treat SUD and mental health disorders that are not specialized. To bridge the gap in care, policy is needed to integrate SUD and mental health services. Additionally, the psychiatry field needs to change as a considerable amount of stigma around substance use still exists (Zisman-Ilani et al., 2023, pp. 201–203).

Mental health care providers perpetuate negative stereotypes regarding sufferers of SUD. They may feel less inclined to treat these patients because they are seen as harder to treat (Zisman-Ilani et al., 2023, pp. 201–203). Another commonly held belief is that these patients are less likely to improve. Fear of manipulation for secondary gains, like getting medications, serves as another barrier to treatment (Zisman-Ilani et al., 2023, pp. 201–203). These beliefs regarding SUD and mental health impact quality care in these patients. In addition to mental health care providers, many other health care providers also perpetuate stigma against those with co-occurring disorders (Roussy et al., 2015, p. 1567). Patients with a dual diagnosis have worse health and well-being outcomes. Stigma creates barriers for dual diagnosis patients, such as excessively strict intake requirements, inadequate referrals, feeling judged from their providers, and a lack of comprehensive treatment options (Roussy et al., 2015, p. 1567).

Among available physicians, there is a lack of providers specialized in SUD and mental health disorders. Addiction psychiatry is considered a subspecialty (Zisman-Ilani et al., 2023, pp. 201–203). Although many people are in need, as of the 2020-2021 school year, there were only 92 fellows in addiction psychiatry (Zisman-Ilani et al., 2023, pp. 201–203). This is far too little for the millions of people in need. The need for addiction psychiatrists grows larger while the numbers of addiction psychiatrists dwindle.

A lack of training and specialty in SUD leaves many patients with psychiatrists that cannot or will not treat substance use or other co-occurring disorders. Despite the importance of treating both, many psychiatrists have little to no education on substance use treatment (Zisman-Ilani et al., 2023, pp. 201–203). Addiction therapy makes up only two percent of psychiatric residency (Zisman-Ilani et al., 2023, pp. 201–203). Many medical professionals available are untrained in SUD and co-occurring disorders.

Conclusion

Co-occurring disorders occur in 48% of the US population (Najt et al., 2011, pp. 159–164). Individuals with co-occurring SUD and mental disorders receive insufficient treatment. Few providers specialize in addiction psychiatry, and co-occurring disorders are often treated separately. Oftentimes, one of the disorders is ignored in treatment (Najt et al., 2011, pp. 159–164). Effective treatment includes acknowledgment and treatment of both disorders. In order to achieve better health outcomes, both disorders must be treated (Najt et al., 2011, pp. 159–164).

References

Najt, P., Fusar-Poli, P. & Brambilla, P. (2011). Co-occurring mental and substance abuse disorders: A review on the potential predictors and clinical outcomes. Psychiatry Research. 186(2), 159–164. https://doi.org/10.1016/j.psychres.2010.07.042

National Institute of Mental Health (NIMH). (2021, March). Substance use and co-occurring mental disorders. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health

Substance Abuse and Mental Health Services Administration (SAMHSA). (2023, January 25). Co-occurring disorders and other health conditions. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/co-occurring-disorders#:~:text=The%20coexistence%20of%20both%20a,affected%20by%20a%20mental%20illness.

Zisman-Ilani, Y., Smith, W. R., & Morris, N. P. (2023). Addressing substance use in psychiatric care: an old problem with renewed urgency. Psychiatric Services, 74(2), 201–203. https://doi.org/10.1176/appi.ps.202100724