Mental Health Awareness Month 2022: The Connection Between Mental Health and Addiction

By Lori Ryland, Ph.D., LP, BCBA-D, CAADC, CCS-M, Chief Clinical Officer, Pinnacle Treatment Centers

Co-Occurring Disorders, Integrated Treatment, and Community Support

May is Mental Health Awareness Month (MHAM).

MHAM began as Mental Health Month over seventy years ago, initiated by the mental health advocacy group Mental Health America. The National Alliance on Mental Illness (NAMI) hosts their version of MHAM every May, too. The purpose of Mental Health Awareness Month for both groups is to connect to as many people as possible through every medium possible – internet, television, print media, live events, everything – in order to spread awareness about mental health, mental health disorders, and mental illness in the U.S.

The twin themes for MHAM 2022 are Back to Basics and Together for Mental Health. When we consider these themes together, we realize they’re a perfect match. If the past two years of upheaval in almost every sphere of personal and public life have taught us anything, it’s that we can improve life for everyone if we join together and get back to basics.

With regards to mental health in general, here’s what that means:

• Reducing stigma by sharing stories, personal experiences, and first-hand knowledge of mental health disorders and treatment for mental health disorders with friends, family, and peers
• Raising awareness by sharing evidence-based information on mental health from sources like MHA, NAMI, SAMHSA, NIMH, and the CDC.
• Educating yourself about our current scientific understanding of mental health and addiction disorders, known as the medical model of addiction and the recovery model of mental health disorders/addiction

We’d like to stress that last bullet point: the more you know about what your loved ones or peers are going through, the better you can offer them sincere, compassionate support.

This article is about the intersection of mental health and addiction: when a person has a mental health disorder and an addiction disorder at the same time, they’re called co-occurring disorders.

Mental Health Disorders and Addiction: People Come First

Another quick point: when we talk about addiction in the clinical setting, we use the phrase substance use disorder (SUD). For a person with an opioid use disorder, we say a person with OUD, and for a person with an alcohol use disorder, we say a person with AUD. We no longer use the terms addict or alcoholic in clinical settings.

We apply the same terminology to a person with a co-occurring disorder. Remember, as defined above,  a person with a co-occurring disorder is a person with SUD and/or AUD and a clinically diagnosed mental health disorder at the same time. In the past, people used phrases like mentally ill substance abuser or substance abuser with mental illness. We no longer use those phrases in clinical settings. Instead, we use COD for co-occurring disorders and say a person with COD.

This is another way we can raise awareness and reduce stigma around addiction and mental health: use the person-first language, because it’s an important step toward extending people with CODs the basic human respect they deserve.

Mental Health Disorders and Addiction: Facts and Figures

We’ll start this section with a salient quote from the 2020 SAMHSA publication, “Substance Use Disorder Treatment for People With Co-Occurring Disorders.” This is something everyone should understand, from the average U.S. citizen, to people mental health or substance use disorders and the people who treat them, to their families, friends, and peers:

“Comorbidity [COD] is important because it is the rule rather than the exception with mental health disorders.”

What that means is that when a person has substance use disorder, they’re at increased likelihood of also having a mental health disorder. It also means that when a person has a mental health disorder, they’re at increased risk of having a substance or alcohol use disorder.

Let’s take a look at the latest prevalence statistics on COD in the U.S. We retrieved the following data from the SAMHSA publication cited above and the 2018 National Survey on Drug Use and Health (2018 NSDUH).

Mental Health Disorder and Substance Use Disorder in the U.S: 2018

• 47.6 million people over age 18 (adults) had a clinically diagnosed mental illness
  • That’s almost 20% of adults
• 11.4 million adults had a serious mental illness
  • That’s almost 4% of adults
• Among the 47.6 million adults with a clinically diagnosed mental illness:
  • 9.2 million had an SUD
    • That’s just over 19%
  • In contrast, among adults without a mental health disorder:
    • 5% had an SUD
  • Among the 11.4 million adults with a serious mental illness:
    • 28% also had an SUD

Those numbers tell the story. Over 9 million people in the U.S. have co-occurring substance and mental health disorders, or COD. Among those with COD, 3.1 million had a serious mental illness. The magnitude of those numbers is why groups like MHA host MHAM every year, and they’re why we write articles like this to help spread awareness about the size and scope of this issues, which affects everyone in the country.

Now that we know the prevalence statistics, let’s take a look at the data on treatment for mental health and substance use disorders.

Treatment for Mental Health Disorder and Substance Use Disorder in the U.S: 2018

• Among the 47.6 million adults with mental illness:
  • 56.7% did not receive any treatment at all
  • That’s almost 27 million people
• Among the 11.4 million adults with serious mental illness:
  • 39.5 percent did not receive any treatment at all
  • That’s just over 4 million people
• Among the 9.2 million adults with mental illness SUD:
  • Over 90% did not receive treatment that addressed both conditions
• Among the 3.2 million adults with a serious mental illness:
  • 30.5% did not receive any treatment
  • 56% received treatment for mental health
  • 3% received SUD treatment only
  • 11% received treatment for both

Those numbers illuminate what’s called the treatment gap. That’s the difference between the number of people who need treatment for a specific medical condition and the people who receive appropriate treatment for that medical condition. The data shows that for mental health issues and for substance use issues the treatment gap is large, and of significant concern. The data also shows the treatment gap for people with a clinically diagnosed SUD and a clinically diagnosed mental health disorder – a.k.a. people with COD – is more than large: it’s unacceptably disproportionate, considering what we know about treatment for COD.

What we know is that for COD, an integrated approach to treatment can help people resolve both their substance use and mental health disorders. But when 90 percent of people in need of that treatment don’t get that treatment, we call that an unacceptably disproportionate number – and we can do much better.

Those are the big picture facts on the intersection between mental health and addiction – COD – in the U.S. We’ll talk about evidence-based treatment for people with COD in a moment. First, we want to focus on a specific group of people with COD: people with opioid use disorder (OUD) who are in medication-assisted treatment (MAT).

Co-Occurring Disorders, OUD, and MAT

SAMHSA defines medication-assisted treatment as:

“The use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.”

MAT is known as the gold-standard treatment for people with OUD. Evidence shows MAT reduces opioid use, improves overall survival, increases time-in-treatment, reduces criminal activity, and enables an individual to participate in typical responsibilities of daily life related to work, family, and school.

Like people with the most common substance use disorders, people with OUD on MAT also experience a high rate of COD. Here are the mental health disorders most often associated with OUD:

• Anxiety disorders
• Mood disorders
• Schizophrenia
• Bipolar disorder
• Major depressive disorder
• Conduct disorders
• Post-traumatic stress disorder
• Attention deficit hyperactivity disorder

In addition, people with OUD on MAT may experience polysubstance use – more than one SUD – as well as a mental health disorder. The clinical term for these individuals is also COD. Some of the most common substances used by people with OUD on MAT include:

• Alcohol
• Tobacco
• Stimulants
• Marijuana
• Hallucinogens
• Prescription drugs

Here’s the data on people with OUD and COD:

• 2 million people in the U.S. have OUD
• 77% had another SUD
• 64% had a co-occurring mental health disorder
• 27% had a serious mental illness
• Only 25% of people with OUD and COD received treatment for both

Again, the treatment gap appears. And once again, it’s unacceptably large.

We include this section on MAT not only because many people on MAT also have a mental health disorder, but also because the approach to treatment for people with OUD on MAT follows a similar template to treatment for people with COD: the integrated, whole-person treatment approach.

We’ll elaborate on that now.

Evidence-Based Treatment for People with Co-Occurring Disorders (COD)

The concept of creating a unified approach to treating people with SUD and mental health disorders originated with the publication of the paper “An Integrated Treatment Model for Dual Diagnosis Of Psychosis And Addiction” by Dr. Kenneth Minkoff. While he designed the integrated treatment model for people with psychotic disorders, mental health and addiction professionals quickly realized his model could work for people with SUD and any mental health disorder.

In other words, the integrated model has the potential to work for anyone with COD.

Since its inception and application in inpatient psychiatric treatment centers for people with COD, the integrated treatment model has been successfully applied in the following contexts:

• Community-based addiction and mental health treatment programs
• Programs combining mental health and addiction treatment with supportive housing services
• Programs designed for youth, adolescents, and young adults involved in the criminal justice system
• Outpatient mental health and SUD programs
• Residential mental health and SUD programs
• Opioid-specific addiction treatment programs

Integrated treatment is associated with improved outcomes for people in all these types of programs. The idea of treating the whole person and addressing any and all aspects of their lives that impact their mental health and substance use disorder has proved the most effective approach to date for people with COD. The idea is that health is more than the absence of disease or disorder. Health is a state wherein a person thrives on all levels: personal, home, school, work, and in relationships. Total health is the goal of integrated treatment, as opposed to a narrowly defined definition of health as the absence of illness.

Here are the essential elements of integrated treatment, as defined by SAMHSA.

Principles of Integrated Treatment for COD

1. Simultaneous Treatment

Clinicians address mental health disorders and SUDs concurrently, when possible. In some cases, it takes time for the symptoms of withdrawal to fade. People who go through detoxification after chronic exposure to drugs of misuse begin treatment for mental health issues and addiction once they achieve medical stability.

2. Expert Providers

Clinicians who offer integrated care should have appropriate training, accreditation, and licensure to address substance use and mental health disorders.

3. Sequential Programming

CODs should be treated in a stepwise manner designed to match individual treatment progress. Experts recommend the following sequence:

• Engagement
• Persuasion
• Active treatment
• Relapse prevention

4. Commitment to Treatment

Therapeutic approaches such as motivational interviewing (MI) are important in securing buy-in and belief in the treatment process, especially at the beginning, or engagement phase.

5. Professional Counseling

Clinicians in integrated treatment programs provide addiction counseling to help individuals with COD develop the emotional, psychological, and behavioral coping tools and techniques that support and promote sustainable recovery.

6. Multiple Therapeutic Formats

Clinicians in integrated treatment programs offer a range of therapeutic approaches, including:

• Individual therapy
• Group therapy
• Family therapy

7. Community Support

Individuals with COD in integrated treatment programs have access to community support programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Community support programs like these can help people with COD both during treatment and during independent recovery.

8. Medication

When needed, an integrated treatment plan includes medication – a.k.a. pharmacotherapy or medication-assisted treatment – that’s prescribed by a licensed physician or psychiatrist. When medication is part of an integrated treatment plan, trained clinicians monitor the individual for safety, medication effectiveness, and the presence of any adverse side effects.

Mental Health Awareness and Addiction Treatment

The power of community can help us address and overcome two crises our nation faces at the moment: the mental health crisis and the addiction crisis. We’re aware that the COVID-19 pandemic is ongoing and that there may be surges of various variants over the next several years that impact our public health decisions both as a nation and as individuals. However, given that default set of circumstances, we need to keep our eye on the people we know needed help before COVID-19 and need our help now, during the extended denouement of the pandemic.

The evidence is overwhelming: the type of help people with co-occurring disorders need is integrated treatment. The way we get more people that help is through community advocacy and spreading awareness. The way we become aware ourselves is by learning everything we can about mental health and substance use disorder. This is true for people with friends or family with COD, but it’s also true for everyone. The more we know, as a society and culture, the better we can offer our most vulnerable citizens the compassionate and unconditional support they need and deserve.

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Chris Powell

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