Commentary: Dual Diagnosis: The Status of Treating Co-Occurring Disorders in The U.S.

At least 50 to 75 percent of Americans seeking treatment for a substance abuse problem also have a co-occurring mental health disorder, according to the Center for Substance Abuse Treatment (CSAT). However, training of professionals for treating dual diagnoses in the field is not as frequent as its prevalence among Americans.

To put this into perspective, the lifetime prevalence of individuals with substance abuse or dependence in the general population is 16.7 percent; however, the prevalence is significantly higher among people who suffer from schizophrenia (47 percent), any mood disorder and obsessive/compulsive disorder (both 32 percent) and any anxiety disorder (23 percent).

Given these statistics, Hazelden, the leading addiction and prevention publisher in education, treatment, and behavioral health, and IC&RC (International Certification and Reciprocity Consortium), the world leader in addiction-related credentialing, have joined together to introduce tailored programming, entitled Focus on Integrated Treatment (FIT), addressing this void.

Experts from Dartmouth Medical School and IC&RC discuss below the current state of integrated addiction and mental health treatment and answer common questions about co-occurring disorders.

What exactly is a co-occurring disorder?

Co-occurring disorders, or “dual disorders,” means having both substance use and mental health disorders at the same time. Treating co-occurring disorders is distinctive discipline, which blends the best of mental health and substance abuse treatment into a “third technology,” says Dave Parcher, chair of the IC&RC Co-occurring Disorders Committee. For this reason, there is a specialized co-occurring disorders credential for professionals. IC&RC credentials – the Certified Co-Occurring Disorders Professional (CCDP) and Certified Co-Occurring Disorders Professional Diplomate (CCDPD) – are based on the concept that co-occurring disorders (COD) are more than the sum of their parts.

What do addiction counselors and mental health practitioners need to understand about the treatment of co-occurring disorders?

Only two percent of the 5.6 million adults in the United States who are living with co-occurring substance use and mental health disorders actually receive evidence-based integrated care, due in large part to the lack of professional training on this approach. According to Matthew Merrens, professor of psychiatry at Dartmouth Medical School and the co-director of the Dartmouth Evidence-Based Practices Center, the most effective model of treatment is just that: integrated treatment. Rather than sequential or parallel treatment, integrated treatment involves a single, combined treatment team treating both disorders at the same time and in the same setting. Practitioners, program administrators and government officials need to understand that COD is a third, distinct disorder, Parcher explains. Substance abuse or mental health training alone is not sufficient for dealing with the interaction of both disorders, which are constantly influencing each other.

Why is certification or continuing education in the treatment of co-occurring disorders important for addiction counselors and mental health practitioners?

It is important that both addiction and mental health counselors are proficient in the screening, assessment and treatment of co-occurring disorders. Credentialing advances the treatment of co-ocurring disorders, because it facilitates standardized practice across a wide variety of treatment settings and regulatory environments. Most importantly, it ensures trained, ethical professionals are available to clients, families and communities around the globe.

When looking for training on the treatment of co-occurring disorders, what do clinicians need to know?

Clinicians, at both mental health and addiction centers, need to learn the skills of integrated treatment that are necessary to help their clients attain recovery. For any kind of training, professionals should review the instructors’ experience and credentials, ensure that the format fits a variety of learning styles, and assess the curriculum for appropriate competencies. In particular, learners need to know that training addresses the interaction between the co-occurring disorders.

What are some of the elements needed for a qualified co-occurring disorders treatment program?

First and foremost, staff must demonstrate competency, says Merrens. The following are other essential elements of a qualified co-occurring disorders treatment program:

1. Ongoing training and supervision of clinicians
2. Strong leadership
3. Active, recovery-oriented focus to treatment
4. Community-based treatment, including supported employment, supported education and supported housing
5. Peer recovery and community group programs.

Other important qualities of a program include a clinical supervisor for each unit who has the experience and training for dealing with co-occurring disorders, explains Parcher. As well, knowledge of medications used for both substance abuse and mental disorders is key.

What is the importance of an evidence-based protocol in the treatment of a co-occurring disorder?

Evidence-based practices are validated by many randomized controlled research trials with patients in usual care settings. They are the best treatments available and should be adopted throughout the behavioral health system.

Parcher believes that the growing body of research from around the world is encouraging. It has consistently demonstrated that treatment outcomes are significantly improved when individuals with co-occurring disorders receive integrated treatment.

The Focus on Integrated Treatment interactive, online training program was launched in early 2012. It serves to help addiction treatment and mental health professionals develop the skills necessary to successfully deliver an integrated treatment plan for clients living with a co-occurring substance use and mental health disorder.

Kris Van Hoof-Haines, Executive Director of Media Ventures at Hazelden contributed to this article, in partnership with Matthew Merrens, PhD and Dave Parcher, LCPC, LPCMH, CCS, CCDP-D.

Matthew R. Merrens, PhD, is Visiting Professor of Psychiatry at Dartmouth Medical School and the New Hampshire-Dartmouth Psychiatric Research Center.

Dave Parcher, LCPC, LPCMH, CCS, CCDP-D serves as Executive Director and senior clinical supervisor for an organization providing treatment and prevention services to persons with these co-occurring disorders and provides training seminars for the State Division of Substance Abuse and Mental Health. He serves as the Chair of the IC&RC Co-Occurring Disorders Committee.

9 Responses to Commentary: Dual Diagnosis: The Status of Treating Co-Occurring Disorders in The U.S.

  1. Ben House | January 17, 2012 at 1:25 pm

    Nice advertising for the program they sell. The article speaks to the need, but does nothing to define what the paradigm of treatment might look like.
    It seems to me both disorders have core similarities that could be identified and then treat on what is in common rather than what is different about these conditions. Publish something that speaks to these commonalities, please.

  2. james curtin | January 17, 2012 at 1:38 pm

    When this taylored programming was put together, was working with an adolescent co-occurring disorders population taken into consideration? FIT seems like a much needed appraoch to working with this underserved population.

  3. Jim Sharp | January 17, 2012 at 2:24 pm

    This is another step in healing the fractures in the history of addiction treatment. Gone are the days when ‘alcoholism’ treatment was separate and distinct from “drug” treatment. Most of us have stopped treating nicotine dependence as being totally different from drug dependence. Now, may be we can eliminate the separation between addiction and mental health treatment. Person-centered, wholistic treatment should become state of the art.

  4. Keely Thomas-Moore | January 18, 2012 at 11:46 am

    When mental health issues and substance abuse collides, it becomes this negative perpetuating cycle. The mental illness feeds into the addiction, which in turn tends to worsen the symptoms of the illness, which then feeds into the addiction even more, and on and on. This is why it is important that they are treated together; breaking one doesn’t stop the cycle of the other, which makes treatment short lived. I think there definitely needs to be an increase of dual diagnosis treatment.

  5. susan totten | January 18, 2012 at 1:58 pm

    A problem that is not addressed is one of privacy accorded substance abuse information at a mental health treatment facility. In addition, someone may be being treated for a co occurring disorder, however, the clinical notes must only reflect the mental health aspect unless specified (and this could change)if the information is to be released to an outside provider. This is a problem if the Client would like records released to say social security because they are trying to get on disability and do not want the substance abuse treatment to jeopardized the case. The issue of billing is another hurdle as well.

  6. George Brenner | January 20, 2012 at 1:24 pm

    Dual Diagnosis is an antiquated view of Co-Occurring Disorders. In heaslth care reform and Intergrated Behavioral health we need to exhaust all possibilities to develope a reasonable plan of recovery with the client/patient. As an Addictions Specialist who works in a med-surg hospital setting, I am continuously aware of the complexity of the presentation of substance use disorder symptoms, mental health symptoms, and medical concern presented by the patient. In attempting to refer patients to outpatient services for ongoing care, most MH and ATOD providers are ill equiped to meet the needs of the clients and this typically leads to poor follow-up and outcomes. Since much of this article is about IC&RC and Hazelden, neither have addressed adequately the issues of COD I see daily.

  7. George Brenner | January 20, 2012 at 2:44 pm

    Would have been a plus to reference Mark McGovern, PhD work in this area. This would move the conversation beyond individual competence to treat persons with a COD and look at program/organizational readiness which is also a critical issue. The DDCAT is a useful tool for this purpose.

  8. Carolyn Reuben, L.Ac. | January 21, 2012 at 1:32 am

    When intake workers include questions that elicit the neurotransmitter imbalances of potential clients as clearly laid out in Depression-Free, Naturally by Joan Mathews Larson and in The Mood Cure by Julia Ross, MA, MFT then the intertwining of mental health and addictive disorders will be clear to both the worker and the suffering client. And treatment will first of all repair the broken brain chemistry that leads to both diagnoses. Those of us around the world doing this brain repair have created an educational nonprofit for our own edification and to educate the fields. You can see what I mean at. What is joyful for all of us is how quickly a person’s affect changes when they consume the right amino acid used by their brain to create more of the needed neurotransmitter: L-tryptophan for serotonin; L-tyrosine for the catecholamines dopamine, norepinephrine, and epinephrine; GABA for GABA; and DL-phenylalanine for endorphins. Counselors find they gain a whole week of quality work in groups who have been nourished properly and probation officers find their probationers are reasonable, calm, and aware of consequences when their brains are nourished. Former Chief Probation Officer Barbara Stitt writes about the link between hypoglycemia and criminal behavior in her book Food and Behavior. Mental illness, criminality, and addiction are three intertwined social problems because they all involve neuron systems screaming for missing nourishment to properly function.

  9. Jackie | March 15, 2012 at 7:18 am

    I have been sober for over 5 years but it is by my action and trecaion that I do make that choice thru out my day, which speaks to me I can live on lifes terms. My point is I have to do the next right thing. I didnt learn this kind of thinking in elementary school or living with my parents, it was in the rooms of Alcoholics Anonymous I picked up the tools of living and the power greater then myself to ask for direction.Wouldnt it be cool to start educating young children how to be ok for today I believe it can start with the young adults that move through the 12 step process whether in recovery program of 12 steps or walking into the rooms of AA and rasing your hand .anything is possible through prayer and taking action in your life. I am still a kid inside and reaching down to help the next person who asks. Ask to be open, Ask for help just ask.Grateful for not doing anything alone anymore

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