Better Integration Needed for Treatment of Substance Abuse and Mental Illness

People who suffer from both mental illness and a substance use disorder often receive care from two very different types of systems, creating confusion for patients, their families and clinicians, says Ken Duckworth, MD, Medical Director for the National Alliance on Mental Illness (NAMI).

“If you have schizophrenia, you are thought to have a condition that you aren’t responsible for, so caregivers organize around trying to help you with medication, jobs, housing and benefits,” says Dr. Duckworth, who is an Assistant Clinical Professor at Harvard University Medical School. “Although substance abuse is a brain-based phenomena, our culture holds you accountable for it—they assume it’s your choice, and your recovery.”

Co-occurring mental illness and substance abuse is one of the issues NAMI is focusing on during Mental Illness Awareness Week, October 7-13.

Finding the best treatment for people with co-occurring disorders is so important because these are some of the highest risk, most vulnerable individuals, Dr. Duckworth notes. According to the Substance Abuse and Mental Health Services Administration, about 8.9 million adults in the U.S. have both a mental and substance use disorder. Only 7.4 percent of individuals receive treatment for both conditions, and 55.8 percent receive no treatment at all.

Dr. Duckworth has seen the conflict between the two care systems when he has sent patients with mental illness to an AA meeting, and they have come back and said they were advised to throw out their lithium. “I do notice that within the culture of AA, there is still some variability in the acceptance of biochemical intervention,” he says. “This is a complicated area, because chemical dependence has caused tremendous suffering. However, I don’t view the use of lithium as chemical dependency.” Some AA groups are completely supportive of medications to treat mental illness, he adds.

He also sees variability in how suboxone is viewed as a treatment for opioid dependence. “Some major substance abuse treatment centers don’t believe in it,” he says. “As a field, we have not come to an agreement on this.”

Dr. Duckworth says more needs to be done to integrate mental health and substance abuse treatment. One critical need is increased training in co-occurring disorders for psychiatry residents. He does see some improvement in this area. “When I was in training, psychiatrists didn’t use AA as a key resource for patients,” he says. “Now, psychiatrists are using AA, NA, Al-Anon and peer resources.”

He sees several other encouraging signs the fields are starting to work together. One is the growing use of peer support in mental health, which grew out of substance abuse treatment. Another is the increasing use of depression screening in substance abuse programs. “We still don’t have a fully integrated service system, but we are better off than we were 10 or 15 years ago,” he commented. “As a field, we’re going in the right direction.”

3 Responses to Better Integration Needed for Treatment of Substance Abuse and Mental Illness

  1. Patricia Fulton | October 12, 2012 at 1:58 pm

    I agree with Dr. Duckworth’s position that more needs to be done to foster integration between substance abuse and mental illness treatment. However, it is important to note that the integration most go beyond referral to AA to address substance abuse disorders. AA is a self-help support to substance abuse treatment and should not be viewed as an adequate substitute for medically supervised treatment interventions. Furthermore, within the self-help movement there are meetings such as Double Trouble which are supportive of persons with co-occurring CD and MH recovery efforts.Until the medical profession begins to embrace their role in addressing the chronic, progressive disease of chemical abuse and dependence there will continue to be fragmented and and two-tiered approach to treating those with co-occurring disorders.

  2. Joel Rice | October 16, 2012 at 10:55 am

    I am an overwhelmingly busy psychiatrist doing psychiatric and addiction work in a variety of settings. The entire treatment system from top to bottom, addiction and psychiatry, is all about money and turf and not very concerned about science or quality. It is embarrassing. The whole system is sick. It is only the spark in my patients’ eyes that keeps me working.

    • Mike | August 13, 2013 at 11:31 am

      I read your comment to an old article re: mental health and substance abuse tx. I am a father of a 29 year old who has suffered enough from both addiction and MH. He has been to so many tx centers that I can’t remember them all. Many of the most highly regarded in the country. He has been treated by some of the most well known psychiatrists at UCLA, Harvard, and others. All to no avail…your comments re: money and turf are so true! Would you know of a place that is different? That cares about the patient and is willing to go the extra mile and get out of the “dual diagnosis” box to help someone like my son? It’s been so long…thanks, Mike. My email address is

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