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Concurrent Disorders

Considerations for Evidence-Based Policy

Gulrose Jiwani and Julian Somers (co-authors)

Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 10

The term ‘concurrent disorders’ can refer to any disorders that occur at the same time. For the purpose of this article, concurrent disorders refers to being affected by both a substance use disorder and another mental disorder.

The US National Comorbidity Study (1996) reported that 29% of the general population aged 15-54 had a concurrent alcohol and/or drug problem and mental disorder in the past year. Recent British Columbia data (2002) indicate that over 70% of people aged 15-64 receiving addictions treatment services are also receiving mental health services; and, 20-40% of people with mental illnesses also have been treated for an alco hol and/or another substance use disorder. Numerous studies in different countries confirm that having either a substance use problem or another mental disorder increases the probability of having both types of problems at the same time.

The presence of concurrent disorders increases the complexity of a person’s treatment and the potential severity of their health condition. Persons with concurrent disorders generally have more severe psychiatric symptoms and are at higher risk for suicide, family violence, HIV infection, homelessness, incarceration and rehospitalization. Concurrent disorders have also been associated with high rates of violence and criminal behaviour Despite the prevalence and burden of illness associated with concurrent disorders, the essential continuum of effective interventions is poorly understood and insufficiently supported.

Individuals presenting with concurrent disorders have historically encountered a treatment system that has been ill-prepared to meet their needs. Moreover, epidemiological studies such as the Ontario Health Survey suggest that the people most likely to present for help are those who have the most severe symptoms and multiple cooccurring problems.6 This finding highlights two significant needs: first, that treatment for people seeking help must be responsive to multiple needs simultaneously; second, that services must be provided for people with less acute symptoms, including early intervention and population health initiatives.

Historically, services for mental health and substance use have been administered and implemented separately. The separation of services results in treatment that is provided either sequentially – first one issue, then the other – or in parallel form – in which treatment providers at separate locations implement treatment plans to treat each condition separately but at the same time. The treatment needs of persons with cooccurring mental health and substance use problems differ from the treatment needs of those with either a substance use problem or a mental health problem alone. Evidence about best practice suggests strongly that treatment that addresses both the substance misuse and mental health issues should be present at the same time The recent Health Canada Best Practices report (see preceding article) focused on synthesizing research information and on developing recommendations for the screening, assessment and treatment/support of persons with concurrent disorder.

Based on the evidence, effective health policy would promote:

  • general societal awareness of factors contributing to good mental health or to mental disorders with or without concurrent substance use disorders

  • identification of at-risk populations for whom the development of mental health and substance use problems may be prevented or dealt with at an early stag

  • access to relevant information and self-management resources that support active participation of individuals and families in addressing concurrent disorders

  • evidence-based mental health and addictions treatment for individuals and families

  • effective matching of treatments and resources to individuals in need

  • flexibility in the systems of care and diverse services, affording individuals with a choice of services, and the ability to enlist in different services at different points in time.

  • case management providing consistent and supportive client contact

  • support for siblings and family members in managing their own mental health

  • continuous, integrated professional development for health care providers in mental health and addictions

  • multiple entry points to services and support

  • sharing of relevant information between appropriate care providers

  • co-ordinated planning across health authorities and other partners at the municipal, regional and provincial levels

  • ongoing implementation of evidence-based practices for concurrent disorders

The BC Ministry of Health Services is developing an Addictions Planning Framework for the health system in BC. The Framework is intended to assist health authorities and other stakeholders in the development of integrated services for addictions, including concurrent disorders. In addition, the Ministry is supporting improved services for concurrent disorders through better integration of primary care and mental health service providers. Information on both initiatives is available from the authors.

No best practice can be presumed to be best long into the future, so we need to repeatedly redefine and implement better practices. To support this constant evolution, we need to consciously create a system that facilitates knowledgesharing and the linkage of research with practice. This requires co-operation at all levels, from grassroots to policy-making, from groups of individual practitioners to groups of organizations with related mandates, and from individuals and families to researchers. All have roles in the synthesis of information, application of knowledge to practice, and within the cycle of continuously-feeding information from practice and research back into the world of evidence. Synergies are necessary and will develop through recognition of individual and collective responsibilities, mandates, capacities and resources. Best practices needs to be more than a goal or an endpoint; it needs to be a philosophy, a mindset that influences actions taken at every step in the process, by every stakeholder involved, and throughout every step in the evolution of the system of care for people with concurrent disorders.

In conclusion, we are currently challenged to develop an integrated, evidence-based continuum of mental health and addictions services throughout British Columbia. In so doing, it is important to ensure timely access to treatment options and support to increase people’s capacity to make healthy choices. Health care providers need support for ongoing professional development regarding evidence-based prevention and treatment services in relation to concurrent disorders. Collectively, we are all responsible for ensuring that ‘every door is the right door.’

 
About the Authors

Gulrose, RN, MN is the Nursing Consultant for Mental Health and Addictions, BC Ministry of Health Services. She can be contacted by email at gulrose.jiwani@gems8.gov.bc.ca

Julian, PhD, is a faculty member in UBC's Department of Psychiatry, and Director of the Centre for Telehealth at UBC's Mental Health Evaluation and Community Consultation Unit (Mheccu). Dr Somers can be contacted by email at julian.somers@ubc.ca

Footnotes
  1. Kessler, RC Nelson, CB, McGonagle, KA, Edmund, MJ, Frank, RG & Leaf, PJ, (1996). The epidemilogy of co-occuring addictive and mental disorders: Implications for prevention and service utilization.Americian Journal of Orthopsychiatry, 66 17-31.

  2. BC Minstry of Health Services. (2002) Mental Health and addictions analyses.

  3. Hall, W (1996). What have population surveys revealed about substance use disorders and their comorbidity with other mental disorders.Drug and Alcohol Review, 15, 157-170

  4. Steadman, HV, Mulvey, Ep, Monahan, J, Robbins, PC, Applebaum, PS, Grisso, T et al. (1998). Violence by people discharged from acute psychiatric inpatient facilities, and by others in the same neighbourhoods.Archives of General Psychiatry, 55, 393-401.

  5. Wallace, C Mullen, PE, & Burgess, P. (in press). Offending in a population of people with schizophrenia. American Journal of Psychiatry.

  6. Ross, HE, Lin, E, & Cunningham, J. (1999). Mental health use: A comparsion of treated and untreated individuals with substance use disorders in Ontario. Canadian Journal of Psychiatry, 44(6), 570-577.

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