W. J. Wayne Skinner - Concurrent Substance Use and Mental Health Disorders: An Information Guide

Contents

Authorship

The Client and Family Information Guide series originated in the Social Work Department of the Clarke Institute of Psychiatry, one of the four organizations that merged in 1998 to form the Centre for Addiction and Mental Health (CAMH). Since then, these guides have become an important part of the CAMH publishing program.

Concurrent disorders is a relatively new field. To learn about it, we have drawn on the wisdom of people from a wide variety of mental health and substance use backgrounds. We thank the author teams who produced the other guides in this series:

Christina Bartha

Pamela Blake

Dale Butterill

David Clodman

April Collins

Robert Cooke

Donna Czuchta

Dave Denberg

Martin Katzman

Kate Kitchen

Stephanie Kruger

Alice Kusznir

Roger McIntyre

Sagar Parikh

Carol Parker

Jane Paterson

Neil Rector

Margaret Richter

Kathryn Ryan

Mary Seeman

Cathy Thomson

Claudia Tindall

Collaboration with CAMH Publication Services has been essential in creating this guide. Caroline Hebblethwaite and Anita Dubey deserve special recognition for their expertise and skill in producing this guide.

Acknowledgment

The authors would like to pay special tribute to clients at CAMH and their families who, through their openness, have taught us so much.

Introduction

This guide is for people with concurrent disorders and for their families. It is also for anyone who wants basic information about concurrent disorders, their treatment and their management. This guide should not replace treatment from a health professional.

The term concurrent disorders covers many combinations of problems. This guide talks about issues that are common to most concurrent disorders. Other guides in the series offer more details about specific mental health problems (see for a list of titles).

1 What are concurrent disorders?

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 addiction to cannabis
• borderline personality disorder and heroin addiction
• depression and addiction to sleeping pills.

(Addiction can be defined as the presence of the 4 C s: C raving, loss of C ontrol of the amount or frequency of use, C ompulsion to use, and use despite negative C onsequences.)

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 diagnos is is used when a person has an intellectual disability and a mental health problem.

How common are concurrent disorders?

A large American study by Reiger and colleagues (1990) 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.

2 What are the symptoms of concurrent disorders?

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: