1.5 An introduction to treatment

A Family Guide to Concurrent Disorders - Part I: What are concurrent disorders?

Detecting substance use and mental health problems

Because of the overlap of symptoms between mental health and substance use disorders, it is often difficult to make a firm diagnosis in the early stages of treatment. For example, symptoms resulting from intoxication and withdrawal can look a lot like symptoms of mood and anxiety disorders. A period of stopping, or cutting down on, substance use is often necessary before therapists can say whether a client has a substance use problem or a mental health problem—or both.

The best way to tell the difference between the symptoms caused by substance-related and other mental health problems is to observe the person when no substances are being used. However, experts don't agree on how long the person needs to stop using substances before a separate problem can be identified. Usually, the required period of abstinence depends on the substances being used and the suspected mental health problem. For example, drugs that stay in the body for a long time (e.g., long-acting benzodiazepines) may need many weeks of abstinence for withdrawal symptoms to taper off so that an accurate diagnosis can be made. For drugs that stay in the body for a shorter period of time (e.g., alcohol, cocaine), both the intoxication and the withdrawal stages will likely be briefer. In this case, it may be possible to make a firm diagnosis with shorter periods of abstinence.

Where do people find treatment?

Substance use services range from withdrawal management services, through community- based assessment and treatment, to short- and long-term residential resources. Mental health services include psychiatric emergency rooms, outpatient mental health clinics, acute-stay hospital beds, extended residential care and assertive community outreach teams for people who previously could only be supported in institutions. Many people get treatment for substance use and mental health problems from family doctors or other primary care services.

A framework (developed in the United States) illustrates where people are most likely to look for treatment. People may move back and forth among the quadrants at various stages of recovery from substance use and mental health problems.

Figure 1-1: The Quadrant Framework
(Click the image to see a larger view)

The quadrant framework suggests that where a person has:

• both substance use and mental health problems of low to moderate severity, primary health care (e.g., family doctors) and community health resources are the core resources to draw on
• a substance use problem of high severity, with a mental health problem of mild to moderate severity, specialized substance use services are the lead resources, with mental health services providing collaborative care
• a mental health problem of high severity, with a substance use problem of mild to moderate severity, specialized mental health services are the lead resources, with substance use services providing collaborative care
• both substance use and mental health problems of high severity, strong evidence suggests that integrated care by a single, multidisciplinary team is the most effective way to provide continuing care and support.

Co-ordinated care

In the past, mental health and substance use services have not been well connected. They have tended to concentrate on one set of problems and view the other as a secondary problem that will clear up once the core problem is addressed. However, we know that if one of the co-occurring problems is not addressed, both problems usually get worse, and additional complications often arise.

Most communities have resources that could provide collaborative programming. In some cases, this already happens. In others, services in both systems need to work together more effectively to provide client-centred care for people with complex needs. We discuss strategies for navigating the treatment system in Chapter 7 .

Treatment principles

When care for substance use and mental health problems is more co-ordinated and integrated, people do better. Concurrent disorder treatment initiatives focus on improved screening and assessment, more specialized programming, and co-ordination (by one person, or a treatment team) of substance use and mental health treatment. Five principles guide how to care for people with co-occurring problems:

1. People with co-occurring disorders are people first. Too often, these individuals pay too high a price for co-occurring disorders (SAMHSA, 2003).
2. Co-occurring problems are under-identified but common.
3. Co-occurring problems are complex but understandable.
4. Co-occurring problems are challenging but responsive to care.
5. Co-occurring problems require responses that go beyond separate addiction and mental health treatment.

People who have co-occurring substance use and mental health problems are some of the most vulnerable people in our society and in our health care system. Evidence suggests that if we address their problems in more co-ordinated and collaborative ways, they are more likely to reduce their substance use and improve their mental functioning. For many people, this is a long, complex process. Often family members are the most constant companions in the journey to recovery. At points in the journey, the family may be called on to be advocate, support person and sometimes case manager. In the rest of the guide we offer tools and strategies to help you do this.

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