In Co-Occurring Disorders, Which Receives Treatment First?
For years, mental health professionals disagreed about how to structure therapy for a patient who had both a substance use disorder and a mental health disorder, often leaving patients with no treatment at all.
The patient would seek care for a mental health disorder such as depression or anxiety. The mental health provider would conduct an assessment. As soon as the patient delivered a positive response to a substance use screen, the provider would refer her to an addiction treatment center to get sober. The patient would arrive at the center, where another screen would find the patient suffered from depressive disorder and would be sent back to the mental health clinic.
Patients would say, “Whatever door I go through, it’s not the right door.” They would fall through the cracks while mental health professionals argued about which disorder took priority.
Ultimately, the question of which disorder to treat first is irrelevant. The patient suffers from both disorders and needs immediate treatment.
For physicians, risk accompanies the commitment to treat. Sometimes, drug use mimics psychiatric disorders. Is this person really anxious or is this a side effect of stimulants? Is the patient really depressed or is that the alcohol talking? But physicians do not have the luxury of taking a wait and see approach. If people could stop using without help, they would.
Many people who suffer from a psychiatric condition often self-medicate with drugs or alcohol. They may not be able to afford a physician or treatment, or they may not want to admit they have a mental health issue. Many people now consider it more acceptable to seek treatment for substance abuse than for mental health disorders, a big step forward in public opinion 20 years ago. As a result, what first appears as a substance use disorder often has roots in a mental health disorder. However, that does not mean treating mental health disorders before treating substance abuse.
Even when patients begin treatment for a mental health disorder, they may continue to self-medicate because they do not like the way the prescribed drugs make them feel. Such medications may make patients restless or cause sleeplessness, which might lead to patients drinking or smoking marijuana to relax. This behavior derails treatment. Alcohol reduces the effectiveness of many drugs, particularly antidepressants, and causes many more health risks. Marijuana, especially synthetic marijuana, which is often cut with toxic fillers, can exacerbate significantly symptoms when taken with psychotropic medications.
If a treatment team does not look at the effect of the mental health disorder on the patient’s recovery from substance abuse or the effect of substance abuse on the patient’s mental health condition, it is like rowing with one oar in one direction and the other oar in the opposite direction. The team and the patient make no progress.
The best practice for patients with co-occurring mental health and substance use disorders addresses all areas and pulls together a team of psychologists, psychiatrists and counselors with expertise that mirrors the patient’s issues. In the Malibu program, 90 percent of those seeking treatment for substance use disorders also suffer from mental health disorders.
An integrated plan and treatment program allows the team to build rapport with a patient, help him or her with recovery, and address their mental health issues. There’s also a parallel process, during which the patient receives treatment for both disorders simultaneously, but from different teams. This is a process commercial or public payers may require. While it’s challenging to coordinate, this parallel process works.
Either way, a patient must work on both conditions nearly simultaneously to recover long term. Otherwise, an alcoholic may be sober for 90 days, feel well, but continue to engage in pathological behaviors that undermine recovery. Pressing without proper tools or support that stabilize mental health will likely return to the bottle.
The first step is to stop using. With counseling, an addict’s brain slowly recovers, allowing the patient to understand his or her behavior while also working on mental health disorders. A violent alcoholic, for instance, must understand what triggers drinking and rage, and develop tools for anger and impulse control as much as for sobriety. Working on both simultaneously will produce the best outcome.