CONCURRENT DISORDERS




How are we defining concurrent disorders?



A concurrent disorder (CD) combines both a mental health problem and a substance use disorder.

Substance use disorder involves dependence on or abuse of substances, such as alcohol, prescription

and/or over-the-counter medication or illegal drugs. A person with major depression who also abuses

alcohol has a concurrent disorder, for example, as does a person with schizophrenia who abuses

cannabis. In the context of this project, it does not include use of nicotine.

Concurrent disorder is also known as co-morbidity. In the United States these disorders are sometimes

called dual diagnosis or dual disorder. In Canada, dual diagnosis usually refers to someone with a

developmental disability and mental illness.



The impact of concurrent disorders



The prevalence of concurrent disorders among people with serious mental illness is higher than many

people realize. Recent research indicates that between forty and sixty percent of people with substance

use disorder (with addictions to alcohol and/or street drugs) also have at least one mental illness1.

People with serious mental illnesses such as schizophrenia who also have substance use problems tend to

experience a wide range of serious problems. Common issues include:



􀂃 more severe psychiatric symptoms, such as depression and hallucinations

􀂃 more dramatic effects after using substances, including a greater number of blackouts

􀂃 greater chance of not following treatment plans

􀂃 physical health problems

􀂃 increased experiences of stigma

􀂃 financial problems

􀂃 housing instability and homelessness

􀂃 poorer management of personal affairs

􀂃 serious relationship problems with family members

􀂃 more verbal hostility, tendency to argue, disruptive behaviour, aggression

􀂃 greater likelihood of ending up in jail

􀂃 increased suicidal feelings and behaviours



Having concurrent disorders affects not only the person experiencing the disorders, but also that person’s

family members and friends. As problems become more complex, family members are often confused

about which problems are causes, and which are results. It is difficult for families to understand why their

relative continues to use alcohol or other drugs when the consequences can be so severe.

The needs of people with serious mental illness and substance use disorder are complex; the problems

posed by the severity of the symptoms of the disease, and the persistent stigma which surrounds mental

illness and addictions are often compounded by the lack of integrated treatment services in the

community.



The national context



The recently released Kirby Report highlights the need for change in many areas of mental health and

addictions treatment in Canada. The report specifically mentions the high rates of concurrent disorders,

and the need to improve the way services are delivered to concurrent disorders clients.

The report cites the impact of the “culture clash” between mental health and addiction services on clients

who need both services. This clash means that they are often excluded from accessing either system of

care. The disconnect between the two treatment systems and their differing philosophies has created a

major gap for people with concurrent disorders, so that many people who needed help “just got lost”.

The Kirby Report and the 2001 report on Best Practices in Concurrent Mental health and Substance Use

Disorders make specific recommendations for transforming the way services are delivered to people with

concurrent disorders, in terms of program and systems-level efforts to support integration between

mental health and addictions sectors. Both reports also recommend cross-training for staff from both

sectors, to share knowledge, perspectives, and better equip staff to meet the needs of those with

concurrent disorders.

The need for tools which can transform information from the best practices report and other sources into

more user-friendly advice was highlighted in an article written by Dr. Brian Rush, the leader of the team

who produced the best practices report. The article also emphasized that although implementation of the

recommendations of the best practice report is essentially a provincial responsibility, the dissemination

process could benefit from more focus and leadership at the national level, and that a national forum or

focal point for discussion and sharing of ideas and experiences is needed.

“In the interface between addiction and mental health, the old concept was that if you deal with the

mental health problem first, the addiction will go away on its own”.



Prevalence



Recent literature on prevalence states that between 40-60 % of individuals with severe mental illness will

develop a substance use disorder at some point during their lives, and about half currently meet criteria

for substance abuse or dependence. For people with schizophrenia specifically, population surveys have

consistently shown elevated rates of alcohol use disorders (about three times the risk) and drug use

disorders (about five times the risk). Several studies show that about half of youth in the first episode of

schizophrenia also have or will develop a substance use disorder.



Service Implications



There is a substantial amount of literature describing the poor coordination between mental health and

addiction services, a situation that has been shown to contribute significantly to poor consumer

outcomes. A better integration between mental health and addictions services is seen as part of the

solution, but there are several levels of service integration that need to be addressed: systems level and

program level. Additionally, there is a need for upgrading the general capacity to address concurrent

disorders across all service providers, not just within highly specialized services.

Substance abuse/dependence and severe mental illness can interact in several complex ways that have

important implications for screening, assessment and the planning of treatment and support. The Health

Canada Document “Best Practices: Concurrent Mental Health and Substance Use Disorders” (2001)

emphasizes that those who experience overlapping severe mental illness and substance use problems

require interventions that address both disorders concurrently. A concurrent disorders strategy should

therefore include screening, assessment, treatment and aftercare interventions that target both types of

disorders with equal emphasis and importance.

The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States has

recently produced a document titled Overarching Principles to Address the Needs of Persons with

Cooccurring Disorders (2006). It is an overview paper which outlines 12 principles for service providers

working with people with concurrent disorders. The principles are intended to help guide both systemic

and clinical responses. The principles, or best practice statements, are grouped into two categories – the

first to guide systems of care, and the second, for individual providers.



Issues specific to people with schizophrenia



People with serious mental illness and substance use disorder are a high-need subpopulation of

concurrent disorders clients, and have unique needs and issues. People with severe mental illnesses such

as schizophrenia are more sensitive to the effects of alcohol and other drugs due to increased biological

vulnerability and, therefore, experience more negative consequences from relatively small amounts of

alcohol and other drugs.



Non-Clinical Issues



Information on the non-clinical issues that are of importance to those with concurrent disorders and their

families has tended to come mainly from the grey literature, such as websites of non-governmental and

support associations, with one major exception. A new resource, Concurrent Disorders: A Resource for

Families (Centre for Addiction and Mental Health (CAMH) in production) brings together the results of a

multi-site pilot study conducted by CAMH, of support and education groups for family members of people

with concurrent disorders. The aim of the groups was to help family members become better informed

about concurrent disorders, develop coping skills, and find ways of working collaboratively with service

providers and relatives to manage their mental health and substance abuse issues.

This comprehensive resource offers practical information for family members on various aspects of

concurrent disorders, providing an introduction to mental health and addiction issues, their impact on

family members, treatment options, and recovery. While the guide addresses concurrent disorders in

general, much of the information it contains is directly relevant to people who have schizophrenia and

substance use disorder.

(This guide is available for any family members at The Nipissing Family Program)

Please call April for information.

For a list of sources please see: http://www.schizophrenia.ca/CD_Discussion_Paper.pdf