Co-occurring disorders in substance abuse treatment: Issues and prospects

The Journal of Substance Abuse Treatment has dedicated an issue to co-occurring disorders. This article stands out for balance and avoiding the myopic and psychiatry hyping findings often seen in articles on the subject.

First, is does a good job distinguishing between general population prevalence and clinical population prevalence. What it doesn’t do (Because the research isn’t there.) is distinguish between acute vs. chronic mental illness or abuse vs. dependence. Further, in discussing assessment, it acknowledges that real world conditions lead to overdiagnosis of mental illness in this population:

Ideally, the assessment of mental disorders would occur only after permitting a period of abstinence that extends up to a month or more to avoid the risk of confusing the client’s presenting condition with the effects of his or her drug use ([Center for Substance Abuse Treatment, 2005], [Hasin et al., 1998] and [Quello et al., 2005]). The press of clinical programming often does not typically allow for such a deliberate strategy even where assessment does take place. Thus, in substance abuse treatment, clinicians may feel constrained to adapt practices to less-than-ideal conditions and accept the noise associated with the influence of substance use on assessment practices and results. One potential outcome of this less-than-ideal process is an overidentification of mental disorders, which may be a significant contributing factor to both the high prevalence rates reported by programs for CODs and findings of the effectiveness of single-disorder treatments for individuals identified as showing evidence of multiple disorders. To counter the risk of error in early diagnosis, it has been suggested that clinicians make use of multiple assessments conducted over time (Center for Substance Abuse Treatment, 2005) and rely on brief screening instruments at intake to determine if a later diagnostic assessment is warranted (cf. [Center for Substance Abuse Treatment, 2005] and [Quello et al., 2005]).

Another strength of the article is that it again, examines real world conditions and acknowledging that treatment as usual is effective for people with mild to moderate mental illness:

…it is important to take note of findings from several studies that individuals manifesting low to moderate levels of mental disorder in association with substance abuse appear to respond positively in terms of both drug use and psychiatric symptoms to the nonspecialized treatment provided in drug abuse programs. However, those same studies also point to the importance of specialized treatment specifically responsive to the needs and functioning of those showing moderate to severe levels of mental disorder.