Mental Health Conditions and Comorbid Disorders

What is Comorbidity?

Comorbidity describes two or more disorders or illnesses occurring in the same person. They can occur at the same time or one after the other. Comorbidity also implies interactions between the illnesses that can worsen the course of both (National Institute on Drug Abuse, 2018).

What is an Opioid Use Disorder?

Opioid Use Disorder is a problematic pattern of opioid use that leads to serious impairment or distress (Providers Clinical Support System, 2017).

What is a Substance Use Disorder?

Substance Use Disorder (Durg Addiction) is a disease that affects a person’s brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication (Mayo Clinic, 2017).

Prevalence of Issues Between Mental Health and Opioids

Mental Health and Comorbid Disorders are significant factors that are associated with Opioid use. Investigations of overdose events show that opioid use disorder (OUD) is a common characteristic among individuals experiencing an overdose, as is the co-use of other substances, including benzodiazepines, cocaine, and alcohol. In addition, co-occurring mental illness has been linked to increased risk for opioid misuse and overdose. Based on the 2015–2017 National Surveys on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (Jones & Mccance-Katz, 2019):

  • 1.1% or approximately 2,083,400 Americans aged 18–64 had a past-year Opioid Use Disorder; 0.7% had a Prescription Opioid Use Disorder (RxOUD), and 0.3% had a Heroin Use Disorder (HUD).
  • Any past-year co-occurring substance use disorder or nicotine dependence was found among 77.2% of those with OUD, 67.6% of those with RxOUD, and 82.7% of those with HUD
  • Mental illness was common among adults with OUD, with 64.3% having Any Mental Illness in the past year and 26.9% having Serious Mental Illness in the past year.

In 2018, the National Survey on Drug Use and Health (NSDUH) suggests that 47.6 million adults 18 years of age and older reported having any mental illness (AMI), 20.2 million people aged 12 or older reported struggling with a substance use disorder (SUD), and 9.2 million adults reported having co-occurring mental health and substance use disorders. Also, the NSDUH found an estimated number of 2 million people who were diagnosed with specifically an opioid use disorder. (Substance Abuse and Mental Health Services Administration, 2019). 

Risk Factors

It’s important to note that although mental disorders and substance use disorders can co-occur, it doesn’t mean that one caused the other. On the other hand, several risk factors that are associated with the development of co-occurring disorders are (National Institute on Drug Abuse, 2018):

  • Specific Genetics can be triggered when an individual uses certain substances
  • Stress and Trauma 
  • Self-Medication for mental health conditions

Prevalence of Treatment for Comorbid Disorders

Regarding treatment services for comorbid disorders, only 8.3 percent of adults with Co-Occurring Disorders reported that they received treatment that addressed both their mental health and substance use disorders in 2017 (Substance Abuse and Mental Health Services Administration, 2019).

Generally, among all the adults who receive addiction treatment only 7% are treated for both substance use and mental health disorders, and more so over 55% of those who have dual diagnoses do not receive any treatment (Foundations Recovery Network, 2020).

As for substance use and mental health treatment (Jones & Mccance-Katz, 2019):

  • Recipients of substance use disorder treatment services in the past year was reported by 34.5% of adults with OUD, 38.4% for adults with OUD and AMI, and 38.2% for adults with OUD and SMI
  • Recipients of mental health treatment services in the past year was reported by 54.7% of those with OUD and AMI and by 64.6% of those with OUD and SMI
  • Receiving both mental health and substance use disorder treatment services in the past year was reported by 24.5% of those with OUD and AMI and by 29.6% of those with OUD and SMI.
  • Nearly 75% had a past-year co-occurring substance use disorder or nicotine dependence with 1 in 4 having an alcohol use disorder, 1 in 6 having a use disorder related to cannabis or sedatives/tranquilizers, 1 in 8 having a cocaine use disorder, and 1 in 10 having a methamphetamine use disorder. Of particular concern was the high prevalence of mental illness among people with OUD, including 1 in 4 adults with OUD having co-occurring SMI in the past year.
  • Approximately one-third of adults with OUD received any substance use disorder treatment services in the past year. Moreover, a large minority of those with OUD and AMI or OUD and SMI did not receive any mental health treatment services in the past year and far fewer received both mental health and substance use disorder treatment services

Barriers to Treatment

As for barriers to treating people with comorbid disorders, the significant factor that results in limited access to treatment is the lack of treatment programs specifically providing services for comorbid disorders. In 2018, 99.8% of Substance Use Disorder treatment facilities surveyed through the National Survey of Substance Abuse Treatment Services reported having clients in treatment with a diagnosed Co-Occurring Disorder (COD) (Substance Abuse and Mental Health Services Administration, 2020).

However, only 50% of the facilities indicated that they provided specifically tailored programs or group treatments for clients with CODs. The 2018 National Mental Health Services Survey reported similar findings of only 46% of mental health service facilities offered COD-specific programming (Substance Abuse and Mental Health Services Administration, 2020).

Facilities most likely to offer COD programming were: 

  • Private psychiatric hospitals (65%), 
  • Veterans Administration medical centers (56%), 
  • Multi setting mental health facilities (59%), and 
  • Community mental health centers (54%) 

Facilities least likely to offer COD programs were:

  • Partial hospitalization/day treatment facilities (37%), and 
  • General hospitals (40%). 

A national survey of 256 SUD treatment and mental health service programs found only 18 percent of addiction programs and 9 percent of mental health programs were rated as COD “capable” (in terms of their capacity to adequately deliver COD services) (McGovern, Lambert-Harris, Gotham, et al., 2014). 

Researchers have identified several interrelated challenges that create barriers to serving people with Comorbid Disorders. Mental and substance use disorder usually provides different systems of care which creates a variety of administrative, financial, and human resource restrictions. The program structure, assessment, treatment, and continuity of care protocols in many mental health clinics are not well suited to meet the needs of clients with Comorbid Disorders (3–6). Also, when mental health providers try to collaborate with specialty substance abuse treatment providers, there are challenges associated with treatment access and care coordination such as (Padwa, Guerrero, Braslow, et al., 2015):

  • organizational failure to sustain integrated care
  • limited support for co-occurring disorder treatment training 
  • diagnostic and billing restrictions
  • perceived shortcomings of the substance abuse treatment system
  • challenges communicating with substance abuse treatment providers
  • difficulty reconciling different treatment approaches

References:

Foundations Recovery Network. (2020). Co-Occurring Disorders. [Infographic]. Dualdiagnosis.org. https://dualdiagnosis.org/infographics/co-occurring-disorders/.

Jones, C., & Mccance-Katz, E. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence, 197, 78–82. https://doi.org/10.1016/j.drugalcdep.2018.12.030.

Mayo Clinic. (2017, October 26). Drug addiction (substance use disorder). Retrieved August 07, 2020, from https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112

McGovern, M., Lambert-Harris, C., Gotham, H., Claus, R., & Xie, H. (2014). Dual Diagnosis Capability in Mental Health and Addiction Treatment Services: An Assessment of Programs Across Multiple State Systems. Administration and Policy in Mental Health and Mental Health Services Research, 41(2), 205–214. https://doi.org/10.1007/s10488-012-0449-1.

National Institute on Drug Abuse. (2018, August). Comorbidity: Substance Use Disorders and Other Mental Illnesses DrugFacts. Retrieved August 08, 2020, from https://www.drugabuse.gov/publications/drugfacts/comorbidity-substance-use-disorders-other-mental-illnesses.

Padwa, H., Guerrero, E., Braslow, J., & Fenwick, K. (2015). Barriers to Serving Clients With Co-occurring Disorders in a Transformed Mental Health System. Psychiatric Services, 66(5), 547–550. https://doi.org/10.1176/appi.ps.201400190.

Providers Clinical Support System. (2017, December 6). Opioid Use Disorder: What is Opioid Addiction? – PCSS. Retrieved August 07, 2020, from https://pcssnow.org/resource/opioid-use-disorder-opioid-addiction/.

Substance Abuse and Mental Health Services Administration. (2019). Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. 44-46. Retrieved August 07, 2020 from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf.

Substance Abuse and Mental Health Services Administration. (2020). Substance Abuse and Mental Health Services Administration. Integrated Treatment for Co-Occurring Disorders. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-02-01_004.pdf.