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SUBSTANCE USE DISORDER COMPARED TO OTHER MENTAL DISORDERS
Substance Use Disorder Compared to Other Mental Disorders
Deanna McPherson, Chelsea Spencer, & Austin Wilmot
Dr. David Patterson
George Warren Brown School of Social Work
Washington University in St. Louis
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Introduction
A common dilemma encountered by clinicians, insurance providers, and legislators alike,
is determining whether substance abuse is a typical mental illness or a unique disorder of its
own. Distinguishing whether substance use disorder is fundamentally different from other mental
disorders influences decisions on how substance use disorders should be treated and ultimately,
how the research and treatment of these disorders should be funded. The treatment of individuals
with substance use disorders and co-occurring mental disorders has become a topic of great
interest due to the large prevalence of co-occurring disorders. In a 2012 national survey on
substance abuse and mental health, of the 20.7 million adults with a substance use disorder
within the past year, 40.7% had a co-occurring mental illness (Substance Abuse and Mental
Health Services Association [SAMHSA], 2013). Furthermore, among the 43.7 million adults in
2012 with a mental illness, 19.2% met criteria for a substance use disorder (SAMHSA, 2013).
Considering these statistics, it makes fiscal sense why some insurance companies only pay for
substance abuse treatment if another mental disorder is present (Fisher & Harrison, 2012, p. 138139).
Beyond making fiscal sense, integrated treatment that simultaneously addresses an
individual’s substance use and co-occurring mental illness has been associated with better
treatment outcomes, such as decreased substance use and improved psychiatric symptoms and
functioning (SAMHSA, 2011). Despite endorsements of various substance abuse and mental
health organizations for holistic, integrative care, such treatment is not always practical, and is
far from commonplace within the current healthcare system. Drake, O’Neal, and Wallbach
(2008) found that individuals with co-occurring disorders were often treated for one disorder or
the other, and tended to be passed back and forth between independent service systems with
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incompatible interventions. This brings up a second matter of contention, regarding whether
individuals with substance use disorders should be treated alongside individuals with various
other mental disorders.
Therefore, determining whether a substance use disorder is a typical mental illness is
necessary to ensure competent treatment and care of such disorders. The following paper will
examine how substance use disorders compare to other mental disorders in diagnostic
characterization, prevalence, and treatment, with a special emphasis on best practices in treating
substance use disorders as well as policy implications.
Mental Disorders
Differentiating between substance use disorder and the typical mental illness is a matter
of how we operationally define these concepts. In order for a concept to be scientifically
investigated, it must be explicitly defined so that it can be measured. A reliable and valid
definition ensures that researchers and clinicians are examining the same phenomenon. Because
mental disorders tend to manifest themselves differently depending on the individual, their
environment, and other extraneous factors, defining what a “typical” mental disorder is can be
difficult.
The American Psychiatric Association (APA) Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM 5) defines a mental disorder as “a syndrome characterized
by clinically significant disturbances in an individual’s cognition, emotion regulation, or
behavior that reflects a dysfunction in the psychological, biological, or developmental processes
underlying mental functioning” (American Psychiatric Association [APA], 2013). The most
common mental disorders in the U.S. are depressive disorders, anxiety disorders, trauma related
disorders, and bipolar disorder (National Institute of Mental Health [NIMH], 2012). It is
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estimated that 9.1% of the population would meet the criteria for a personality disorder, placing
personality disorders among the most common disorders (NIMH, 2012).
The Substance Abuse and Mental Health Services Association (SAMHSA) (2013)
defines any mental disorder (AMI) as a diagnosable mental, behavioral, or emotional disorder,
excluding developmental and substance use disorders. SAMHSA differentiates AMI from severe
mental illness (SMI), which it defines as “a diagnosable mental, behavioral, or emotional
disorder (excluding developmental and substance use disorders) that has resulted in serious
functional impairment, which substantially interferes with or limits one or more major life
activities” SAMHSA, 2013). An individual be 18 years or older to meet this criteria. In 2012, an
estimated 18.6% of the U.S. population had AMI. Of that 18.6%, 4.1% had SMI. Finally, of the
18.6% of the national population with AMI (43.7 million people), 41% received treatment in the
year 2012 (SAMHSA, 2013).
Substance Use Disorders
Diagnostic Criteria and Prevalence
According to the DSM 5, substance use disorder is indeed its own mental disorder
diagnosis. Substance use disorders are broken down into 10 substance classes. The essential
features of a substance use disorder include cognitive, behavioral, and physiological symptoms
that produce clinically significant impairment. Additional criteria that are applicable across
classes of substances are a) tolerance, b) significant time spent obtaining, using, or recovering
from substances, c) an intense desire to use, or cravings, d) risky use of the substance, and e)
withdrawal upon the cessation of substance use. According to SAMHSA, 8.5% of the U.S.
population aged 12 and older were classified with substance use disorders in the year 2012
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(SAMHSA, 2013). In 2012, only 1.5% of the population received treatment for their substance
use disorders (SAMHSA, 2013).
Treatment
In the U.S., substance use disorders are currently treated with a variety of approaches and
modalities. On surface level, many of these treatment vehicles appear similar to how typical
mental illnesses are treated. For example, both substance use disorders and other mental
disorders are treated in various settings, by clinicians with differing theoretical orientations, and
with a range of treatment modalities. Often times, substance abuse and other mental disorders are
co-occurring, providing further support for treating individuals with these disorders together or
in the same manner.
Despite treatment similarities and co-occurrence, substance use disorders have unique
characteristics which contrast from the typical or most commonly occurring mental illnesses in a
number of ways, influencing how they must be treated and managed. For some individuals
struggling with their substance use, detoxification services are necessary before further
therapeutic work is possible. The goal of detoxification programs is to address both the physical
and mental/psychological aspects of substance use. According to one treatment manual published
in 2009, detoxification programs are intended to:
“provide a safe withdrawal from the substance of dependence and enable
individuals to become alcohol- or drug-free[,]…provide withdrawal that protects
people's dignity…[and] prepare individuals for ongoing alcohol and drug abuse
treatment” (Office on Child Abuse and Neglect, 2009).
Depending on the substance(s) of abuse, and severity of impairment involved, it may be
appropriate for treatment to begin without cessation of the substance use, taking an approach of
motivating the client to make changes to his/her lifestyle.
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In terms of the societal treatment of individuals with substance use disorders, much
stigma can impact the lives of these individuals, which can come from virtually any source—
whether through friends, family, employers, or mental health professionals themselves. The
labels “addict” or “alcoholic” are widely associated with negative, disempowering meanings that
are used to identify whole persons as if “all they are” is an addict or alcoholic. These labels can
go beyond indication of the mental health condition itself and stigmatize the individual as
irrecoverable, deficient, or defective in character. However, it is important to note that some 12step groups make use of these terms toward therapeutic ends, therefore it is ultimately the
meanings that each individual attributes to these labels that impacts the purpose of identifying
oneself with such language. Nonetheless, these labels typically remain highly stigmatizing and
dehumanizing on the systemic level.
Whether substance use disorders should be treated separately from other mental illnesses
is not a question of either/or, but a more complex issue that is dependent on factors unique to the
individual client. The manner by which treatment can be separated from other mental illnesses is
both a matter of space (e.g., the setting of treatment—individuals with substance use disorders
are separated from individuals with other mental illnesses) and time (e.g., the singular concern of
substance use is the primary target of treatment interventions versus targeting other mental
illnesses with the same client during session). Individuals with substance use disorders have
unique needs different than those with other mental illnesses. A client’s needs are best
understood by gaining a thorough understanding of the client’s history and a substance abuse
assessment. Ideally, a treatment plan is then developed according to the identified needs of the
client.
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Using the medical field as a point of comparison, it is true that not all physical health
issues can be addressed by one’s general practitioner. Therefore, another service provider, a
specialist, is identified as a point of referral. In a similar way, substance use treatment facilities,
specific support groups, and treatment modalities that offer more specialized care can be
indicated. Although treatment models that originated for use with other mental illnesses,
Cognitive Behavioral Therapy (CBT), for example, have been adapted for use with clients with
substance use disorders, the techniques or methods involved can look very different (Carroll,
1998). The intention behind recognizing this “similar, yet different” dynamic in the treatment of
substance use issues is to remain focused on how a particular client may or may not benefit from
separate treatment of their conditions, and whether it is warranted.
The reality that an individual can be “dually diagnosed” with both a substance use
disorder and another mental disorder, such as a mood disorder, brings to light further
complexities that must be addressed. If an individual is dually diagnosed, it is sometimes the
unfortunate case that they are passed back and forth between a service provider that treats the
substance use and another service provider that treats the other disorder. It can also be harmful
when these individuals are refused treatment by service providers because of the dual nature of
their diagnosis (National Alliance on Mental Illness [NAMI], 2014). Whether one treats the
substance use disorder before or after other concerns is, again, a complex question. Depending
on the severity of impairment in functioning and client motivation, the need to reduce or
eliminate the substance use could be a priority of treatment or looked at as secondary to other,
overshadowing diagnoses. A client with a dual diagnosis should not be treated “as if” the other
diagnosis does not exist, but with awareness of the inextricable link between the symptomology
of each mental illness.
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Best Practices in the Treatment of Substance Use Disorders
Best practices for treating substance use disorders remain a challenge for mental health
practitioners. The identification of such practices for clients who present dually with substance
abuse and a mental illness has undergone much iteration in the substance abuse and mental
health communities. Such practices offer a glimmer of hope to those in the field working on
these issues as well as for clients who are attempting to find solace and healing with their
illnesses. Many approaches to treating co-occurring disorders that do not meet strict standards of
evidence are nevertheless commonly accepted and believed to be effective based on the best
available research, clinical expertise, individual values, common sense, and a belief in human
dignity (SAMHSA, 2011). Therefore, it is almost necessary for clinicians and practitioners to
utilize practices that are available to them. It is also important to note that best practices will also
have to incorporate suitable options for insurance and financing of such operations as well as key
imperatives for program settings and structures of such facilities.
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the
National Institute on Drug Abuse (NIDA) have researched and established best practices for
these populations. NIDA has highlighted best practices in working with co-occurring conditions
of substance abuse and mental illnesses that are categorized into two primary sections. One
highlights psychotherapy approaches that work well with a particular group, while the other
section speaks to the integration of substance abuse treatment and mental health services. Within
therapeutic references in working with patients with comorbid conditions, there are those that
distinguish best approaches for adolescents and adults, albeit separately. There are more
prevalent co-occurring illnesses, such as schizophrenia and smoking and alcohol and depression
that have recommended approaches when working with said populations. Lastly, age and gender
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are also considered in the development of best practices for treatment of dual diagnoses. Steady
progress is being made through research on new and existing treatment options for co-morbid
conditions, and through health service research on implementation of appropriate screening and
treatment within a variety of settings, including criminal justice systems (NIDA, 2010).
Psychotherapies
Adolescents.
Promising behavioral therapies for adolescents with comorbid conditions are
Multisystemic Therapy (MST), Brief Strategic Family Therapy (BSFT) and Cognitive
Behavioral Therapy (CBT) (NIDA, 2010). Each therapeutic approach is able to work with the
substance abuse alongside an adolescent’s subsequent mental illness. MST targets key factors
(attitudes, family, peer pressure, school and neighborhood culture) associated with serious
antisocial behavior in children and adolescents who abuse drugs (NIDA, 2010). BSFT targets
family interactions that are thought to maintain or exacerbate adolescent drug abuse and other
co-occurring problem behaviors (NIDA, 2010). CBT is the most effective psychotherapy for
children and adolescents with anxiety and mood disorders, and also shows strong efficacy for
substance abusers (NIDA, 2010). Some evidence suggests the utility of incorporating
Therapeutic Communities (TCs) for adolescents who have been in treatment for substance abuse
and related problems (NIDA, 2010).
Adults.
Promising behavioral therapies for adults with comorbid conditions are Assertive
Community Treatment (ACT), Dialectical Behavior Therapy (DBT), Exposure Therapy,
Therapeutic Communities (TCs), and Integrated Group Therapy (IGT) (NIDA, 2010). There are
unique benefits associated with each approach. TCs focus on the resocialization of the individual
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and use broad-based community programs as active components of treatment (NIDA, 2010).
ACT integrates the behavioral treatment of severe mental disorders, such as schizophrenia, and
co-occurring substance use disorders (NIDA, 2010). DBT is designed to specifically reduce selfharm behaviors including drug abuse (NIDA, 2010). Exposure Therapy is a behavioral treatment
for use with anxiety disorders, and involves repeated exposure to or confrontation with a feared
situation, object, traumatic event, or memory. Several studies suggest that exposure therapy may
be useful for individuals with co- morbid PTSD and cocaine addiction, although retention in
treatment is difficult (NIDA, 2010). IGT is a new treatment developed specifically for patients
with bipolar disorder and drug addiction, designed to address both problems simultaneously
(NIDA, 2010). CBT has also been shown to be effective for adult populations suffering from
drug use disorders and a range of other psychiatric problems (NIDA, 2010). Most clinicians and
researchers agree that broad spectrum diagnoses and concurrent therapy will lead to more
positive outcomes for patients with comorbid conditions (NIDA, 2010). There are similarities in
evidence-based treatments or best practices for both adolescents and adults which show promise
in treating both the substance use and the co-occurring illness. As the research continues to
develop, more psychotherapies may be added to the list of recommended practices.
Federal Responses
The collaboration between the National Association of State Alcohol and Drug Abuse
Directors and the National Association of State Mental Health Program Directors in their
scientific pursuit of more effective treatment interventions for people with a co-occurring
disorder has produced a national effort to: foster improvements in treatment, provide a
classification of treatment settings, reduce the stigma associated with mental disorders, and
increase the acceptance of substance abuse and mental health concerns as a standard part of
SUBSTANCE USE DISORDER COMPARED TO OTHER MENTAL DISORDERS
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healthcare information gathering (Cherry, 2008). SAMHSA’s reports seek to investigate the best
methods of bridging science and treatment for people with co-occurring disorders. According to
their guidelines, the standards for treatment should be as follows: consumer driven; delivered
from an integrated system of care that fosters an equitable distribution of services; that the best
recovery practices available; welcoming and based on a no wrong door concept and, lastly;
culturally competent (Cherry, 2008). The ability to enter into different systems and/or services
that have the best intentions for the client at stake will allow for best methods in treating these
individuals. Coordination of services amongst these systems will increase the likelihood
effective outcomes for clients.
Integrated treatment means that the same clinicians or teams of clinicians, working in one
setting, provide appropriate mental health and substance abuse interventions in a coordinated
fashion (SAMSHA, 2010). This should also include effective medications for such dual
diagnoses. Such medications exist for treating opioid, alcohol, and nicotine addictions and for
alleviating the symptoms of many other mental disorders, yet most have not been well studied in
comorbid populations (NIDA Research Report Series, 2010).
Effectiveness
Historical reviews of effective treatment modalities for people who have co-occurring
diseases, such as substance dependence and mental illness, show a fierce debate between two
systems that have only in the recent decades concluded that an integrated approach would be one
best suited for all. However this is not a simple answer as having both entities and trains of
thought combined into one system must be one that appreciates and thoroughly understands the
nuances of each. This is in large part due to the fact that generally people who have a substance
use disorder and a mental illness tend to have more severe symptoms (NIDA, 2010).
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Social service systems have not been well designed to treat persons with co-occurring
illnesses. There are substance abuse treatment facilities that mandate clients, who may also have
a co-occurring mental illness, to detox in order for them to receive treatment. NAMI (2014)
claims that “treatment programs designed for people whose problems are primarily substance
abuse are generally not recommended for people who also have a mental illness as these
programs tend to be confrontational and coercive and most people with severe mental illnesses
are too fragile to benefit from them” (p. 5). If these clients’ are served at a mental health clinic
and present with a substance use problem, they may be told to come back when they have
abstained for an established period of time. Traditional mental health treatment programs often
offer services that are contingent upon clients’ abstinence from alcohol and other drugs (Barrett
& Marlatt, 1999 as cited in Mancini, Hardiman & Eversman, 2008). Clients are referred back
and forth between treatments, in what some have called "ping-pong" therapy (NAMI, 2014).
Desirable programs for this population should take a more gradual approach, where clients with
a dual diagnosis can proceed at their own pace in treatment (NAMI, 2014).
NIDA (2010) states that “although research supports the need for comprehensive
treatment to address co-morbidity, provision of such treatment can be problematic” (p. 9). As
previously mentioned, there are different systems that address different disorders. Physicians and
mental health professionals are most often the front line of treatment for mental disorders,
whereas drug abuse treatment is provided in assorted venues by a mix of health care professions
(NIDA, 2010). Some substance abuse treatment centers ban the use of medications in their
facilities, for instance, with those who may also be suffering from a mental illness (NIDA, 2010).
It is widely known that the criminal justice system carries a significant weight of persons mental
disorders, many of whom could meet the criteria for multiple diagnoses. It is estimated that about
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45 percent of offenders in State and local prisons and jails have a mental health problem
comorbid with substance abuse or addiction (NIDA, 2010). Having an integrated approach in
such a setting could be the perfect incubator to test the effectiveness of dual services.
Policies
Cherry (2008) believes that the “substance abuse treatment and mental health treatment
fields are not compatible, that they cannot be integrated effectively unless treatment philosophies
and policies in both fields are willing to change, and that neither field has developed a set of
treatment interventions sufficient to recommend either of them in their entirety” (p. 10). What is
needed are "hybrid" programs that address both illnesses together. especially at a local level,
which requires considerable advocacy efforts (NAMI, 2014).
Federal grants through governmental agencies have also been able to show effectiveness
to lawmakers on the value of integrating such systems as well as the cost effectiveness
(SAMSHA, 2010). More recently, researchers and policy makers have begun to make the
important distinction between integrated services and integrated systems involving fundamental
changes in the way agencies share information, resources, and clients (SAMSHA, 2010). Policy
approaches that may aid in integration have components such as flexible financing, bridging
treatment philosophy differences, modifying administrative oversight and accountability
practices. However, because state mental health resources are targeted to those with severe
mental disorders and the Medicaid-eligible, access to public health services can be limited
(Burnam & Watkins, 2006). These challenges can hopefully be overcome with the Affordable
Care Act and discussions about the evolvement of Medicaid.
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Conclusion
Distinguishing whether substance use disorders are fundamentally different from other
mental disorders is a complex task with many stakeholders. How substance use disorders are
defined and conceptualized have treatment and policy implications. Substance use disorder is
recognized by the DSM 5 as its own mental disorder diagnosis, however, substance use disorders
and co-occurring mental disorders has become a topic of great interest and debate. Several
factors play a role in how substance use disorders can be characterized as “similar, yet different”
from other typical mental illnesses. The unique needs of clients who present with dual diagnoses
or who require specialized substance abuse treatment speak to the sense that substance use
disorders have unique characteristics that are differentiated from other typical mental illnesses.
Systemically, the present political and financial infrastructure recognizes this differentiation via
policy-making and treatment of substance abuse as an issue to itself. Best practices to meet the
unique needs of these clients are vast and subjective, in some cases, and are based upon which
system the client chooses to pursue. Effective approaches for substance abuse only will likely
continue to incorporate the use of self-help or support groups and, in some instances,
medications. Psychotherapies that have been utilized with this population continue to glean
results with comorbid clients suffering from substance use and a mental illness. The Federal
government's response to treat substance use is through funding mechanisms which will allow
researchers to find the evidence-based treatments for this population. Grantees such as SAMSHA
and NIDA are able to create programs based on their findings which offer a glimmer of hope for
this population. Overall, regardless of how substance use disorder is differentiated from other
typical mental illnesses, efforts to ensure competent treatment and care of the unique needs of
this population are an on-going priority with the substance abuse treatment community.
SUBSTANCE USE DISORDER COMPARED TO OTHER MENTAL DISORDERS
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References
Burnam, M., & Watkins, K. E. (2006). Substance Abuse With Mental Disorders: Specialized
Public Systems And Integrated Care. Health Affairs, 25(3), 648-658.
doi:10.1377/hlthaff.25.3.648
Carroll, K. (1998). A cognitive-behavioral approach: Treating cocaine addiction. Retrieved from
http://archives.drugabuse.gov/TXManuals/CBT/CBT1.html
Cherry, A. L. (2008). Mixing oil and water: Integrating mental health and addiction services to
treat people with a co-occurring disorder. International Journal Of Mental Health &
Addiction, 6(3), 407-420. doi:10.1007/s11469-007-9074-8
Fisher, G. L., & Harrison, T. C. (2012). Substance abuse: Information for school counselors,
social workers, therapists, and counselors (5th ed.). Upper Saddle River, NJ: Pearson.
Mancini, M. A., Hardiman, E. R., & Eversman, M. H. (2008). A review of the compatibility of
harm-reduction and recovery-oriented best practices for dual disorders. Best Practice In
Mental Health, 4(2), 99-113.
National Alliance on Mental Illness. (2013). Mental illness facts and numbers. Retrieved from
http://www.nami.org/factsheets/mentalillness_factsheet.pdf
National Alliance on Mental Illness. (2014). Dual diagnosis: Substance abuse and mental
illness. Retrieved from
http://www.nami.org/Content/ContentGroups/Helpline1/Dual_Diagnosis_Substance_Abuse_and_Mental_Illness.htm
National Institute of Mental Health. (2012). Serious mental illness (SMI) among adults.
Retrieved from http://www.nimh.nih.gov/statistics/SMI_AASR.shtml
SUBSTANCE USE DISORDER COMPARED TO OTHER MENTAL DISORDERS
16
National Institute of Mental Health. (2014). What is schizophrenia? Retrieved from
http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml#part5
National Institute on Drug Abuse. (2010). Comorbidity: Addiction and other mental illnesses.
Retrieved from http://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf
Office on Child Abuse and Neglect, Children's Bureau., ICF International. (2009).
Treating substance use disorders. Retrieved from https://www.childwelfare.gov/
pubs/usermanuals/substanceuse/chapterfive.cfm
Substance Abuse and Mental Health Services Administration. (2011). How to use the evidencebased practices KITs: Integrated treatment for co-occurring disorders (HHS Publication
No. SMA 11-4633). Rockville, MD: Substance Abuse and Mental Health Services
Administration.
Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012
national survey on drug use and health: Mental health findings (HHS Publication No.
SMA 13-4805). Rockville, MD: Substance Abuse and Mental Health Services
Administration.