Concurrent Substance Use And Mental Health Disorders

an Information Guide
c ONCURRENT SUBSTANCE USE
AND MENTAL HEALTH DISORDERS
W.J. Wayne Skinner, MSW, RSW
Caroline P. O’Grady, RN, MN, PhD
Christina Bartha, MSW, CSW
Carol Parker, MSW, CSW

cONCURRENT SUBSTANCE USE
AND MENTAL HEALTH DISORDERS
An Information Guide
W.J. Wayne Skinner, MSW, RSW
Caroline P. O’Grady, RN, MN, PhD
Christina Bartha, MSW, CSW
Carol Parker, MSW, CSW
A Pan American Health Organization /
World Health Organization Collaborating Centre

CONTENTS
Authorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1
What Are Concurrent Disorders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
National Library of Canada Cataloguing in Publication
Skinner W. J.Wayne, 1949-
2
What Are the Symptoms of Concurrent Disorders? . . . . . . . . . . . . . . . . . . 5
Concurrent substance use and mental health disorders:
an information guide / W. J.Wayne Skinner, Caroline P. O’Grady.
Includes bibliographical references.
3
What Causes Concurrent Disorders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ISBN 0-88868-474-6
4
How Are Concurrent Disorders Treated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1. Dual diagnosis. 2. Mentally ill—Alcohol use. 3. Mentally ill—Drug
use. 4. Substance abuse. 5. Mental illness. I. O’Grady, Caroline P., 1961-
II. Centre for Addiction and Mental Health III. Title.
5
Recovery and Relapse Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
RC564.68.S55 2004 616.86 C2004-901499-4
Printed in Canada
6
How Concurrent Disorders Affect Families . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Copyright © 2004 Centre for Addiction and Mental Health
No part of this work may be reproduced or transmitted in any form or
7
Explaining Concurrent Disorders to Children . . . . . . . . . . . . . . . . . . . . . . 35
by any means electronic or mechanical, including photocopying and
recording, or by any information storage and retrieval system without
written permission from the publisher—except for a brief quotation
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
(not to exceed 200 words) in a review or professional work
For information on other Centre for Addiction and Mental Health
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
resource materials or to place an order, please contact:
Marketing and Sales Services
Centre for Addiction and Mental Health
On-line Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
33 Russell Street
Toronto, ON M5S 2S1
Canada
Tel.: 1 800 661-1111 or 416 595-6059 in Toronto
E-mail: marketing@camh.net
Web site: www.camh.net
Disponible en français sous le titre :
Les troubles concomitants de toxicomanie et de santé mentale :
Guide d’information
2934/03-04 PM039

AUTHORSHIP
ACKNOWLEDGMENT
The Client and Family Information Guide series originated in the Social
The authors would like to pay special tribute to clients at CAMH and their
Work Department of the Clarke Institute of Psychiatry, one of the four
families who, through their openness, have taught us so much.
organizations that merged in 1998 to form the Centre for Addiction
and Mental Health (CAMH). Since then, these guides have become an im-
portant part of the CAMH publishing program.
Concurrent disorders is a relatively new ﬁeld. To learn about it, we draw
on the wisdom of people from a wide variety of mental health and sub-
stance use backgrounds. We thank the author teams who produced the
other guides in this series:
Christina Bartha
Alice Kusznir
Pamela Blake
Roger McIntyre
Dale Butterill
Sagar Parikh
David Clodman
Carol Parker
April Collins
Jane Paterson
Robert Cooke
Neil Rector
Donna Czuchta
Margaret Richter
Dave Denberg
Kathryn Ryan
Martin Katzman
Mary Seeman
Kate Kitchen
Cathy Thomson
Stephanie Kruger
Claudia Tindall
Collaboration with the Education and Publishing Department has
been essential in creating this guide. Caroline Hebblethwaite and Anita
Dubey deserve special recognition for their expertise and skill in pro-
ducing this guide.
iv
Concurrent Substance Use and Mental Health Disorders
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v

INTRODUCTION
This guide is for people with concurrent disorders and for their families.
It is also for anyone who wants basic information about concurrent
disorders, their treatment and their management. This guide should not
replace treatment from a health professional.
The term “concurrent disorders” covers many combinations of problems.
This guide talks about issues that are common to most concurrent dis-
orders. Other guides in the series offer more details about speciﬁc mental
health problems. They include:
• Depressive Illness
• Bipolar Disorder
• Schizophrenia
• First Episode Psychosis
• Women and Psychosis
• Obsessive-Compulsive Disorder
• Women, Abuse and Trauma Therapy
• The Forensic Mental Health System in Ontario
For more information about these guides, visit our Web site at
www.camh.net/publications/.
An Information Guide
1

In Ontario, the term dual diagnosis is used when a person has an intellec-
tual disability and a mental health problem.
1 WHAT ARE
CONCURRENT DISORDERS?
How common are concurrent disorders?
A person with a mental health problem has a higher risk of having a sub-
A large American study1 found the following rates:
stance use problem, just as a person with a substance use problem has an
increased chance of having a mental health problem. People who have
• 30 per cent of people diagnosed with a mental health disorder will also
combined, or concurrent, substance use and mental health problems are
have a substance use disorder at some time in their lives. This is close to
said to have concurrent disorders.
twice the rate found in people who do not have a lifetime history of a
mental health disorder.
Concurrent disorders can include combinations such as:
• 37 per cent of people diagnosed with an alcohol disorder will have a
mental health disorder at some point in their lives. This is close to twice
• an anxiety disorder and a drinking problem
the rate found in people who do not have a lifetime history of a
• schizophrenia and cannabis dependence
substance use disorder.
• borderline personality disorder and heroin dependence
• 53 per cent of people diagnosed with a substance use disorder (other
• depression and dependence on sleeping pills.
than alcohol) will also have a mental health disorder at some point in
their lives. This is close to four times the rate found in people who do
Many other concurrent disorders are possible, because there are many
not have a lifetime history of a substance use disorder.
types of mental health and substance use problems.
The most common combinations are:
A n o t e a b o u t l a n g u a g e
• substance use disorders + anxiety disorders
In this information guide, we use the phrases “substance use problem” or
• substance use disorders + mood disorders.
“mental health problem” to describe the broad range of situations, from
mild to severe, that a person with concurrent disorders may experience.
An x i e t y d i s o rd e r s
We use the phrases “substance use disorder” or “mental health disorder”
• In general, 10 to 25 per cent of all people will have an anxiety disorder
only where the text refers to a speciﬁc diagnosis.
in their lifetime.
• Among people who have had an anxiety disorder in their lifetime,
Concurrent disorders are also sometimes called:
24 per cent will have a substance use disorder in their lifetime.
• dual disorders
• dual diagnosis
• co-occurring substance use and mental health problems.
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Concurrent Substance Use and Mental Health Disorders
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Ma j o r d e p re s s i o n
• In general, 15 to 20 per cent of all people will have major depression
in their lifetime.
2 WHAT ARE THE SYMPTOMS OF
CONCURRENT DISORDERS?
• Among people who have had major depression in their lifetime,
27 per cent will have a substance use disorder in their lifetime.
Concurrent disorders is a term for any combination of mental health and
substance use problems. There is no one symptom or group of symptoms
B i p o l a r d i s o rd e r
that is common to all combinations.
• In general, one to two per cent of all people will have bipolar disorder
in their lifetime.
The combinations of concurrent disorders can be divided into ﬁve main
• Among people who have had bipolar disorder in their lifetime,
groups:
56 per cent will have a substance use disorder in their lifetime.
• substance use + mood and anxiety disorders, such as depression or
S c h i z o p h re n i a
panic disorder
• In general, one per cent of all people will have schizophrenia in
• substance use + severe and persistent mental health disorders, such as
their lifetime.
schizophrenia or bipolar disorder
• Among people who have had schizophrenia in their lifetime,
• substance use + personality disorders, such as borderline personality
47 per cent will have a substance use disorder in their lifetime.
disorder, or problems related to anger, impulsivity or aggression
• substance use + eating disorders, such as anorexia nervosa or bulimia.
• other substance use + mental health disorders, such as gambling and
When do concurrent disorders begin?
sexual disorders.
Mental health and substance use problems can begin at any time:
To understand and treat a particular combination, we need to look at the
from childhood to old age. When problems begin early and are severe,
speciﬁc problems to see:
recovery will probably take longer, and the person will need to work
harder and have more support. On the other hand, if the problem is
• how severe the problems are
caught and treated early, the person has a better chance of a quicker and
• how the problems affect each other.
fuller recovery.
People often ask, “Which came first: the mental health problem or the
How severe are the problems?
substance use problem?” This is a hard question to answer. Often it is
more useful to think of them as independent problems that interact with
Some people with concurrent disorders have very severe problems with
each other.
both their mental health and their substance use. This makes it hard for
them to function day-to-day. While other people may have milder mental
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Concurrent Substance Use and Mental Health Disorders
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health and substance use problems, the impact on their lives can still
How does each problem affect the other one?
be difﬁcult.
Mental health problems and substance use problems can affect each other
in several ways:
People with concurrent disorders are likely to receive treatment in one of
the following settings:
• Substance use can make mental health problems worse.
• Substance use can mimic or hide the symptoms of mental
• primary health care; for example, family doctors
health problems.
• mental health agencies
• Sometimes people turn to substance use to “relieve” or forget about
• substance use agencies
the symptoms of mental health problems.
• specialized concurrent disorders treatment programs.
• Some substances can make mental health medications less effective.
• Using substances can make people forget to take their medications. If
The treatment setting often depends on how severe a person’s problems are.
this happens, the mental health problems may come back (“relapse”)
or get worse.
High
• When a person relapses with one problem, it can trigger the symptoms
severity
More severe substance
Severe substance use
of the other problem.
use problems; mild
and mental health
to moderate mental
problems
A person with concurrent disorders will often have more serious medical,
health problems
TREATMENT:
social and emotional problems than if he or she had only one condition.
TREATMENT:
ideally with specialized
Treatment may take longer and be more challenging.
mainly in the
care for concurrent
r
oblems
substance use system
disorders
se P
e
U
Milder substance use
More severe mental
and mental health
health problems; mild
problems
to moderate substance
ubstanc
use problems
S
TREATMENT:
in the community
TREATMENT:
with a family doctor
mainly in the mental
health system
Low
Mental Health Problems
High
severity
severity
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3 WHAT CAUSES
CONCURRENT DISORDERS?
4 HOW ARE CONCURRENT
DISORDERS TREATED?
There is no simple cause of concurrent disorders. Each person’s situation
People who have concurrent disorders often have to go to one service for
is different. Here are some reasons why a person might develop both a
mental health treatment and another place for addiction treatment.
mental health and a substance use problem:
Sometimes the services are not connected at all.
• Some people who have a mental health problem may use substances to
However, concurrent substance use and mental health problems are often
feel better. While substance use is very risky in such cases, it can help
related, and they affect each other. So clients have the best success when
people forget their problems or relieve symptoms, at least in the
both problems are addressed at the same time, in a co-ordinated way.
short-term. People sometimes talk about using substances for
The treatment approach usually depends on the type and severity of
“self-medication.”
the person’s problems. A person might receive psychosocial treatments
• Some effects of substance use can mimic symptoms of a mental health
(individual or group therapy) or biological treatments (medications),
problem, such as depression, anxiety, impulsivity or hallucinations. This
or often both.
is sometimes described as substance-induced mental health problems.
• Substance use can cause harmful changes in people’s lives and relation-
Although the overall treatment plan should consider both mental health
ships. For example, substance use problems may cause a person to lose
and substance use problems, it is sometimes best to treat one problem
his or her job. Mental health problems may result from these indirect
ﬁrst. For example, most people who have concurrent mood and alcohol
effects of substance use.
disorders are likely to recover better if the alcohol disorder is treated ﬁrst.
• For some people, a common factor may lead to both mental health and
substance use problems. This factor may be biological. It may also be
As another example, a person who is being treated for concurrent
an event, such as emotional or physical trauma.
problems may have an episode in which the mental health problem gets
worse. Treatment might at that point focus on the mental health problem,
For a person whose mental health is fragile, even moderate amounts of
rather than on the substance use.
substance use may create problems.
Where do people get treatment?
Most people with concurrent disorders have mild to moderate problems
that can be treated in the community, through their family doctor, for
example. People with severe problems may need specialized care for
concurrent disorders.
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What is integrated treatment?
Treatment goals
Clients with severe concurrent mental health and substance use problems
In the past, addiction and mental health treatment services have each had
may need integrated treatment. Integrated treatment is a way of making
different ways of treating problems. They have also had different ways of
sure that treatment is smooth, co-ordinated and comprehensive for the
thinking about problems. Clients who received treatment from both
client. It ensures that the client receives help not only with the concurrent
systems may have been confused by the differences. For example:
disorders, but also in other life areas, such as housing and employment.
Ongoing support in these life areas helps clients to:
• Many addiction services agree that reducing substance use is a realistic
goal for clients at the beginning of treatment. This is called harm
• maintain treatment successes
reduction. As the client moves through treatment, the long-term
• prevent relapses
goal may be abstinence: to stop the use of the substance completely.
• ensure their basic life needs are being met.
However, some mental health programs ask clients to completely
stop using alcohol or other drugs before they can get treatment.
Integrated treatment works best if the client has a stable, trusting, long-
• Many mental health problems beneﬁt from treatment with
term relationship with one case facilitator. This person is a health care
medications. However, some substance use programs may try to help
professional, such as a case manager or therapist. Even though one person
the client stop taking all drugs, including those used to treat mental
is responsible for overseeing the client’s treatment, the client may work
health problems.
with a team of professionals, such as psychiatrists, social workers and
addiction therapists.
Fortunately, staff in many mental health and substance use programs now
work more closely together. As a result, clients may see fewer differences
If all the treatment services are not in one location, two or more
like the ones described above.
programs may work together to co-ordinate treatment. For example, a
therapist in an addiction program might ask new clients questions to see
The ultimate goal of treatment is for clients to:
if they also have mental health problems. If the clients do, the addiction
program could either:
• decide what a healthy future means for them
• ﬁnd ways to live a healthy life.
• treat the mental health problems, or
• refer clients to a mental health agency, and work with that
The treatment plan needs to be customized—this means it will address
agency. Therapists at both agencies would keep in touch about
each client’s particular needs. Both the substance use and the mental
the clients’ progress.
health problems will be addressed with the most appropriate approaches
from each ﬁeld.
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Types of treatment
• how to self-manage the problems (if possible)
• how to prevent future episodes.
Treatment for concurrent disorders includes psychosocial treatments and
medication. Clients may receive one or the other, or both.
P S Y C H O T H E R A P Y
Psychotherapy is sometimes called “talk therapy.” It helps people deal
with their problems by looking at how they:
Psychosocial Treatments
• think
Psychosocial treatments are an important part of treatment for concurrent
• act
disorders. They include:
• interact with others.
• psychoeducation
There are many different types of psychotherapy. Some types are better for
• psychotherapy (counselling, individual and group therapy)
certain problems. Psychotherapy can be either short-term or long-term.
• family therapy
• peer support.
Short-term therapy has a specific focus and structure. The therapist is
active and directs the process. This type of treatment is usually no longer
P S Y C H O E D U C A T I O N
than 10 to 20 sessions.
Psychoeducation is education about mental health and substance use
issues. People who know about their problems are more able to make
In long-term therapy, the therapist is generally less active, and the process
informed choices. Knowledge can help clients and their families:
is less structured. The treatment usually lasts at least one year. The aim is
to help the client work through deep psychological issues.
• deal with their problems
• make plans to prevent problems
Successful therapy depends on a supportive, comfortable relationship
• build a plan to support recovery.
with a trusted therapist. The therapist can be a:
While all people should receive psychoeducation when they begin treat-
• doctor
ment for concurrent disorders, as they move through recovery, they
• social worker
may benefit more from psychoeducation. For people who have milder
• psychologist
problems, psychoeducation alone may be the only treatment they need.
• other professional.
Psychoeducation sessions include discussions about:
Therapists are trained in different types of psychotherapy. They may
work in hospitals, clinics and private practice.
• what causes substance use and mental health problems
• how the problems might be treated
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Co g n i t i v e b e h av i o u ra l t h e ra py
Interpersonal group therapy focuses on the interactions among group
Cognitive behavioural therapy (CBT) is a type of short-term psycho-
members.
therapy. CBT works well for a broad range of concurrent disorders.
Gro u p t h e ra py
In CBT, people learn to look at how their beliefs or thoughts affect the way
Group therapy can help people who have concurrent disorders. Group
they look at themselves and the world. Some deeply held thoughts have
therapy can include treatments such as:
a strong influence on our mood and behaviour. For instance, if we are
depressed and drinking too much and think no treatment will help, then
• cognitive behavioural therapy
we might not seek treatment. CBT helps people identify and change such
• interpersonal therapy
thoughts and learn new strategies to get along better in everyday life.
• psychoeducation.
D i a l e c t i c a l b e h av i o u r t h e ra py
A group setting can be a comfortable place to discuss issues such as family
Dialectical behaviour therapy (DBT) is a type of cognitive behavioural
relationships, medication side-effects and relapses.
therapy. It is used to treat a range of behaviour problems. DBT draws on
Western cognitive behaviour techniques and Eastern Zen philosophies. It
F A M I L Y T H E R A P Y
teaches clients how to:
Families may also be involved in the person’s treatment. Support from
family members can help the person who has concurrent disorders. Family
• become more aware of their thoughts and actions
members may also enter therapy themselves. Therapy for families can offer
• tolerate distress
a range of help. For example:
• manage their emotions
• improve their relationships with other people.
• Families can learn about substance use and mental health problems.
• Family members can enter care as clients themselves.
In s i g h t - o r i e n t e d o r p s y c h o dy n a m i c p s y c h o t h e ra p i e s
Insight-oriented or psychodynamic psychotherapies tend to be longer-
Family therapy can:
term and less structured. These therapies reduce distress by helping
people understand what makes them act the way they do.
• teach families about concurrent disorders
• offer advice and support to family members.
In t e r p e r s o n a l t h e ra py
Interpersonal therapies help clients get better at communicating and
Usually therapists work with one family at a time. Sometimes family
interacting with others. These therapies help people:
therapy is offered in a group setting with other families in similar situa-
tions. Group members can share feelings and experiences with other
• look at how they interact with others
families who understand and support them.
• identify issues and problems in relationships
• explore ways to make changes.
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P E E R S U P P O R T G R O U P S
• selective serotonin reuptake inhibitors (SSRIs): ﬂuoxetine
Peer support groups can be an important part of treatment. A peer
(e.g., Prozac®), paroxetine (e.g., Paxil®), sertraline (e.g., Zoloft®)
support group is a group of people who all have concurrent disorders.
• tricyclic antidepressants (TCAs): amitriptyline (e.g., Elavil®), nortripty-
These people can accept and understand one another, and can share their
line (e.g., Aventyl®), imipramine (e.g., Tofranil®), desipramine (e.g.,
struggles in a safe, supportive environment. Group members usually
Norpramin®), clomipramine (e.g., Anafranil®)
develop a strong bond among themselves. People who have recently been
• monoamine oxidase inhibitors (MAOIs): tranylcypromine
diagnosed with concurrent disorders can benefit from the experiences
(e.g., Parnate®), phenelzine (e.g., Nardil®), moclobemide
of others.
(e.g., Manerix®)
• others: nefazodone (e.g., Serzone®), venlafaxine (e.g., Effexor®),
There are peer support groups for clients and for families. Groups for
bupropion (e.g., Wellbutrin SR®).
clients include Double Trouble groups and Dual Recovery Anonymous.
The Family Association for Mental Health Everywhere (FAME) has groups
An t i - a n x i e t y m e d i c a t i o n s
for families. See page 40 for further information. Although these groups
Anti-anxiety medications are used to treat anxiety. Benzodiazepines are a
are often called self-help, peer support actually offers a type of help called
family of anti-anxiety medications. These drugs are also sometimes used
mutual aid.
to help people who are going through withdrawal from alcohol. They are
mild sedatives (they can cause people to feel relaxed and sleepy).
Biological Treatments
Benzodiazepines are considered safe to use in the short term. If used for a
long time, however, they may cause dependence. For this reason, benzo-
M E D I C A T I O N S U S E D T O T R E A T M E N T A L H E A L T H P R O B L E M S
diazepines are usually prescribed for long-term use only if other medica-
Medications may help control symptoms and prevent them from coming
tions haven’t worked. If benzodiazepines are prescribed, the dose needs to
back. Psychiatric Drugs Explained, by David Healy, is a useful source of
be carefully watched. Anti-anxiety medications include:
information about how medications work. The main types of medica-
tions for mental health problems are:
• chlordiazepoxide (e.g., Librium®)
• diazepam (e.g., Valium®)
• antidepressant medications
• alprazolam (e.g., Xanax®)
• anti-anxiety medications
• lorazepam (e.g., Ativan®)
• mood stabilizers
• buspirone (e.g., Buspar®).
• antipsychotic medications.
Mo o d s t a b i l i z e r s
An t i d e p re s s a n t m e d i c a t i o n s
Mood stabilizers are medicines that help reduce mood swings. They also
Antidepressant medications are used to treat depression. Some are also
help prevent manic and depressive episodes. The three main types of
helpful for anxiety disorders. More than 40 antidepressants are available.
mood stabilizers are:
Examples include:
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Concurrent Substance Use and Mental Health Disorders
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• lithium (e.g., Carbolith®)
• naltrexone (ReVia®) for alcohol or opioid dependence
• valproic acid (e.g., Epival®)
• bupropion (Wellbutrin®, Zyban®) for nicotine addiction.
• carbamazepine (e.g., Tegretol®).
Su b s t i t u t i o n m e d i c a t i o n s
An t i p s y c h o t i c m e d i c a t i o n s
Substitution medications reduce or prevent withdrawal symptoms.
Antipsychotic medications are used to treat psychosis. Delusions and hallu-
They may also reduce or eliminate drug cravings. Combined with
cinations are examples of symptoms of psychosis. There are two main
medical and social support, these medications can help people leave the
types of antipsychotics:
lifestyle that revolves around harmful substance use. Methadone, used to
treat dependence on opioid drugs such as heroin, is the most common
• typical: haloperidol (e.g., Haldol®), chlorpromazine (e.g., Largactil®),
substitution medication.
perphenazine (e.g., Trilafon®)
• atypical: clozapine (e.g., Clozaril®), risperidone (e.g., Risperdal®),
C O M P L I A N C E A N D S I D E - E F F E C T S
olanzapine (e.g., Zyprexa®).
Medications may have troubling side-effects. Many side-effects lessen
with time. If you are having serious side-effects, talk to your doctor. The
M E D I C A T I O N S U S E D T O T R E A T S U B S T A N C E U S E P R O B L E M S
doctor can change the dose or prescribe other medications to reduce or
Medications can also help treat substance use problems. Some are used in
avoid side-effects. Remember, too, that substance use may interfere with
the short-term while others may be needed for longer periods.
the positive effects of medications.
There are three main types of medications that help with substance use:
A doctor will monitor your use of medication. In some cases, the doctor
may check the amount of medication in your blood. This allows you to
• aversive medications
receive the correct dose. The doctor may also check some body organs to
• medications that reduce cravings
see how they are affected by medication.
• substitution medications.
With the proper precautions, the risk of serious complications from med-
Ave r s i v e m e d i c a t i o n s
ications is usually lower than the risks of living with untreated substance
People who take aversive medications will have unpleasant effects if they
use and/or mental health problems.
continue their substance use. An example of an aversive medication is
disulﬁram (Antabuse®), which is used for alcohol dependence.
Special treatment situations
Crav i n g re du c t i o n
Some medications change the way brain chemicals respond to drugs.
During their recovery, people may need specific interventions, such as:
They may block the enjoyable effects of a drug, or reduce cravings for the
drug. Examples of medications that reduce cravings are:
• withdrawal management
• crisis management
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Concurrent Substance Use and Mental Health Disorders
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• relapse prevention
Depending on the situation, a crisis may be managed at home with family,
• hospitalization.
peer and professional support. Sometimes, the person may need to be
hospitalized as a result of a crisis.
W I T H D R A W A L M A N A G E M E N T
People sometimes need short-term help with withdrawal from substance
After the crisis has passed, the person may need a change in the treatment
use. Withdrawal management helps them manage symptoms that happen
approach. The person may need to return to therapy if he or she has
when they stop using the substance. Withdrawal management helps
ﬁnished treatment.
prepare clients for long-term treatment. Clients also learn about
substance use and treatment options.
R E L A P S E P R E V E N T I O N
In their most severe forms, mental health and substance use problems are
There are three types of withdrawal management:
chronic and recurring. This means that, even after a person has received
treatment, the problems may come back, or relapse.
• In community withdrawal management, the person goes through with-
drawal at home. Health care professionals help support and guide the
Relapse is part of the recovery process. A relapse is not a reason to stop
person through this.
treatment. If the person is taking medications for a mental health pro-
• A person may stay in a withdrawal management centre. This is a special
blem, he or she needs to keep taking them.
facility where the person receives more intensive care and supervision.
• Medical withdrawal management may be needed if a client has severe
It is important to acknowledge and discuss the relapse. Relapse can be
withdrawal symptoms, such as seizures or hallucinations. A doctor and
used as:
nurse supervise the withdrawal. The client may stay in hospital or visit
as an outpatient. The client may receive medications to replace the drug
• a chance to learn
or ease symptoms.
• a chance to review the treatment plan
• a chance to renew a plan of action.
C R I S I S M A N A G E M E N T
There may be times when people who have concurrent disorders are in
People who have had a relapse of substance use or mental health pro-
crisis. For example, the person may be in danger of hurting himself or
blems may not need intensive medical care. The relapse may be handled
herself, or other people.
through individual therapy or in a group setting.
It can be very hard for family members to cope effectively with a sudden
H O S P I T A L I Z A T I O N
crisis. It is useful to plan some emergency strategies when the person is
During a severe crisis or relapse, some people may need to be in the hos-
well. This allows everyone to be prepared if anything does happen.
pital. This may be when clients are at risk of serious consequences, due to:
• aggressive behaviour
• taking dangerous risks
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• overdosing
Laws protect the rights of people who are admitted involuntarily. For
• self-harming or suicidal behaviour
instance, a “rights advisor” will visit. The rights advisor will ensure that
• failing to look after their own basic needs.
the client has the chance to appeal the involuntary status before an
independent board of lawyers, doctors and laypeople.
In such cases, the person may stay in the hospital from a few days up to a
few weeks. In hospital, the person may attend group or individual therapy
The police are sometimes needed to help to get a person to hospital.
sessions each day. Clients should expect to leave hospital when:
Family members may agonize over whether to involve the police. They
often feel very guilty about calling the police, even if the police are needed
• follow-up arrangements are in place
to protect the person’s life. Remember, when people threaten suicide, they
• symptoms have improved
are usually pleading for help. They are taken seriously. Suicidal thinking is
• they are able to function safely and care for themselves at home.
often a temporary feeling. When a person feels suicidal, he or she needs to
be kept safe.
Vol u n t a r y v e r s u s i nv o l u n t a r y a d m i s s i o n s
People are usually admitted to hospital voluntarily. This means that they
• agreed to enter the hospital
• are free to leave hospital at any time.
However, in most places, the law also allows any doctor to admit a person
to hospital involuntarily. This means the person may not agree that he or
she needs help, and does not want to be in the hospital. This can happen
if the doctor believes there is a serious risk that:
• the person will physically harm himself or herself
• the person will physically harm someone else.
Each province, state or jurisdiction has its own process for admitting
people to hospital involuntarily. For example, in Ontario, if the person
doesn’t have a doctor, families may ask a justice of the peace to order an
examination by a physician. In the examination, the physician will decide
if the person needs to be assessed in a hospital with a psychiatric facility.
The physician must be able to prove that the person’s illness represents a
risk of harm.
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much on attitude as it does on following a treatment plan. The process of
recovery can include:
5 RECOVERY AND
RELAPSE PREVENTION
• developing self-conﬁdence
Some people with concurrent disorders may feel as if they have too many
• hope and optimism about the future
problems. They may feel these problems are too much to overcome, and
• setting achievable goals
that life will never be good again. They may also feel unable to do all the
• making changes to your housing, lifestyle or employment situation.
things they did before.
A client in recovery is not “cured.” People may still have symptoms and
These feelings are natural and understandable. Yet, treatment, support
struggle with their problems during their recovery. A relapse of substance
and effort can help people with concurrent disorders to live meaningful,
use or mental health problems is often part of the process.
rewarding lives.
Recovery takes time. You may expect to have at least a year of care as
One of the first steps toward recovery is to set appropriate goals and
part of your recovery, and to be involved in different programs in
priorities. This often happens during treatment, but recovery can also
different settings.
happen without the help of professionals.
Family members are also important during recovery. It can help if you
Preventing relapse and promoting wellness
talk about your plans and concerns with family, to receive their support
and feedback.
The following tips may help you prevent relapse and have a healthy
lifestyle.
What does it mean to be “in recovery”?
1. Become an expert on your condition. Ask your treatment provider
about your problems and their treatment. Many resources are available.
Each person has a different idea about what recovery means. The key
These include:
goals of treatment are:
• books
• managing mental health symptoms
• videos
• reducing or ending substance use
• support groups
• reducing the risk of relapse
• information on the Internet.
• improving work life and relationships.
The quality of information varies. Ask your treatment team to recom-
Many people measure recovery by their success in meeting these goals.
mend good sources.
However, recovery is more than this. Recovery is a process; it depends as
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2. Stick to your plan to manage both problems. This includes:
• friends
• leisure activities.
• taking medications as prescribed
• avoiding situations or people that might trigger substance use
A balanced and satisfying life can help you cope with stress. It may reduce
• attending treatment sessions
your risk of relapse.
• taking good care of yourself.
8. Remember how and why you need to stay well. Remind yourself of the
3. Live a healthy life. Eat a healthy diet, sleep well and exercise. Regular
things that help you stay well and the reasons for doing so. Reminders can
exercise can positively affect mood. Try to follow a regular routine that in-
include things like:
cludes activities in the evenings and on weekends. Use your faith, religion
or healing practices that support your recovery.
• carrying photographs of loved ones in your wallet
• keeping a list of positive things in your life.
4. You can’t get rid of stress, so find ways to cope with stress. Many
people use only one coping strategy, or way to deal with stress. Work with
It may also be helpful to carry a list of activities that support recovery, as
your treatment team to ﬁnd strategies to handle day-to-day stress.
well as emergency numbers to contact in a crisis.
5. Have a support network of family and friends. A strong social
network can be a big support. You can nurture and build this network to
help protect you from situations that cause stress. Friends or family may
recognize symptoms of mental health problems or situations that trigger
substance use; they can assist you in seeking help if necessary.
6. Watch for signs of mental health problems or urges to use sub-
stances, and ask for help if you need it. You may be able to sense early
signs of an episode of illness, or the urge to use substances again. Seeking
help at these times may prevent a relapse. If a relapse does happen, getting
help may prevent things from getting worse.
7. Try to balance your life. Remember to do things in moderation. Divide
your time among:
• work
• family
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Family members need to learn how to:
6 HOW CONCURRENT DISORDERS
AFFECT FAMILIES
• communicate effectively
• help when needed
What happens when someone you love has
• know when to let go
concurrent disorders?
• take care of themselves.
When someone has any chronic problem, it affects his or her entire family.
As the relative undergoes treatment, family members may also feel hope
Family members must cope with extra stressors.
and optimism. They may begin to appreciate how hard it is for their rela-
tive and admire the person’s courage. When the person with concurrent
Many family members struggle to accept that their relative has both sub-
disorders has success in treatment, family members may also feel a sense
stance use and mental health problems. Some families may accept the
of personal reward.
mental health diagnosis, but not the substance use problem. They may
think the substance use is a sign of “bad” behaviour. Other families may
accept the substance use, but ﬁnd it hard to accept that their relative has a
Getting treatment for your family member
mental health problem. Some families struggle to understand that con-
current disorders are a relapsing condition, and not an illness with a cure.
It may be hard to get your relative or partner to accept help. The person
may be so discouraged about the situation that he or she may not be able
Family members may feel:
to see how treatment might help. People with concurrent disorders are
more likely than other people to have other health care issues. But they
• guilt
may not have a diagnosis of concurrent disorders. So, even though you
• shame
may suspect the nature of the problem, your relative might refuse to
• grief
accept that he or she needs treatment for concurrent disorders.
• depression
• anxiety
It is best to be supportive when trying to get your relative to accept help.
• a sense of loss.
It is not helpful to be confrontational. One way to be supportive about
getting help is to find where your relative is least resistant to the idea
They need to recognize that the expectations they had for their family
of changing. For example, the person may mention that drinking has
member may change.
a terrible effect on his or her mood. You could then start talking about
drinking. You could use this discussion to start the person thinking about
However, families can play a strong role in recovery. With support and
getting help.
understanding from families, people with concurrent disorders are more
likely to have a successful and lasting recovery.
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R E C O G N I Z E Y O U R O W N F E E L I N G S
When your family member is ready to seek treatment, take an active role
Your own feelings are important. If you accept your own feelings, you can
in helping. An active role could involve, for example:
better help the person who has the concurrent disorders. You may feel:
• ﬁnding treatment centres
• sad that the person has both a substance use and a mental
• setting up an appointment
health problem
• coming to the appointment.
• angry that this has happened to your relative and seriously affects
you as well
With the consent of your family member, you may also be able to give the
• afraid of what the future holds
therapist information that offers insight into the person’s situation.
• worried about how you will cope
• guilty—that somehow you caused the problem
• a deep sense of loss when your relative behaves in ways that you
Care for families
do not recognize
• stressed by the extra tasks you have to take on.
When someone has a serious condition, family members naturally feel
worried and stressed. They spend time comforting or helping their loved
T A K E C A R E O F Y O U R S E L F
one. At the same time, they are also dealing with the usual challenges of
You need to look after your own physical and mental health. To do this,
family life. As a result:
you need to:
• They may ﬁnd that caring for their family member has replaced their
• Find your own limits.
own routines and activities.
• Make time for yourself. Keep up your interests outside the family and
• They may be unsure of how others may respond to the person with
apart from your relative.
concurrent disorders, so they avoid having friends visit their home.
• Try to create a support system of friends and relatives you can rely on.
• Over time, they may lose touch with their own network of friends.
• Think about people you might want to conﬁde in. Substance use
and mental health problems are hard for some people to understand.
R E C O G N I Z E S I G N S O F S T R E S S
Be careful—conﬁde only in people who will support you.
You need to recognize signs of stress in yourself. Often, people take a long
• Consider seeking support for yourself, even if your relative is not in
time to realize how emotionally and physically drained they have become.
treatment. Understanding your relative’s problems and the impact they
This stress can lead to:
have on you will help you cope better. Perhaps join a self-help organiza-
tion or family support program. Local community mental health clinics,
• sleeping badly
substance use treatment agencies or hospitals may offer such programs.
• feeling exhausted all the time
• Acknowledge and accept that sometimes you will have negative feelings
• feeling irritable all the time.
about the situation. These feelings are normal—try not to feel guilty
about them.
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Being ready for a relapse or crisis
Acknowledge and accept your own feelings. Having conﬂicting emotions
Families often avoid talking to their relative about relapses or crises. They
is normal. Knowing this can help you control these emotions, so you can
fear that talking about a crisis will bring one on, or will upset their
support your relative through recovery.
relative. Also, everyone hopes that the last crisis was something that only
happened once, and will not happen again.
2. Encourage your family member to follow the treatment plan. Encou-
rage the person to attend treatment sessions regularly. If the medication
However, the best way to handle a crisis, or possibly avoid one, is to know
doesn’t seem to help, or the side-effects are uncomfortable, encourage the
what to do before it happens. While you focus on wellness, you should
person to:
also plan for a crisis or relapse. This can help both the ill person and the
family to feel more secure.
• speak to the doctor, nurse, therapist or other member of
the treatment team
When your relative or partner is well, plan what to do if problems come
• speak to a pharmacist, or
back. Consider the following:
• get a second opinion.
• Could you both visit the doctor to discuss your relative’s condition
Go with your relative to an appointment, to share your observations. Sup-
and how to deal with a possible crisis?
port your relative’s efforts to avoid things that may trigger substance use.
• Will your relative give you advance permission to contact his or
her doctor?
3. Learn the warning signs of self-harm or suicide. Warning signs
• Do you have your relative’s consent to take him or her to hospital in a
include:
crisis? If so, which hospital has your relative chosen?
• If your relative becomes ill and cannot decide on treatment, does he or
• feeling increasing despair
she agree that you can decide?
• winding up affairs
• talking about “When I am gone . . . .”
You may want to write down the terms that you and relative have agreed
on. This can help to ensure that the terms are followed. You can also build
If the person makes any threats, take them very seriously—get help
a good relationship with a therapist and have a pre-arranged emergency
immediately. Call 911 if necessary. Help your family member to see that
plan to avoid a crisis.
self-harm or suicidal thinking is a symptom of the illness. Always stress
how much you value the person’s life.
Tips for helping your family member
4. When your family member is well, plan how to try to avoid crises.
With your family member, work out how to respond to a relapse or crisis.
1. Learn as much as you can about the causes, signs and symptoms and
Prepare for how you will deal with:
treatment of the problems your family member has. This will help you
to understand and support your family member in recovery.
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Concurrent Substance Use and Mental Health Disorders
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• a substance use relapse
• an episode of mental health problems
• other potential problems.
7 EXPLAINING CONCURRENT
DISORDERS TO CHILDREN
5. Remember your own needs. Try to:
Explaining a mental health or substance use problem to children can be
awkward and difﬁcult. To protect their children, parents may say nothing.
• take care of yourself
They may try to continue with family routines as if nothing were wrong.
• keep up your own support network
This strategy may work in the short term. Over the long term, though,
• avoid isolating yourself
children can feel confused and worried about how their parent’s behav-
• consider entering therapy for yourself
iour has changed.
• acknowledge the family stresses of coping with concurrent disorders
• share the responsibility with others, if possible
Children are sensitive and intuitive. They quickly notice when someone
• don’t allow the problems to take over family life.
in the family has changed, particularly a parent. If the family doesn’t
talk about the problem, children will draw their own, often wrong,
6. Recognize that recovery is slow and gradual. Know that your family
conclusions.
member needs to recover at his or her own pace. You can support
recovery from an episode or relapse in these ways:
Young children, especially those in preschool or early grades, often see the
world as revolving around themselves. If something bad happens,
• Try not to expect too much, but avoid being overprotective.
they think they caused it. For example, a child may accidentally break
• Try to do things with your relative rather than for him or her. That way,
something valuable. The next morning, the parent may seem very
your relative will slowly regain self-conﬁdence.
depressed. The child may then think that breaking the object caused
the parent’s depression.
7. See concurrent disorders as an illness, not a character ﬂaw. Treat your
relative normally once he or she has recovered. At the same time, watch
for possible signs of relapse. If you see early symptoms, suggest a talk with
How much should I tell the children?
the care provider.
Children need to have things explained. Give them as much information
as they can understand.
T O D D L E R S A N D P R E S C H O O L C H I L D R E N
Toddlers and preschool children understand simple, short sentences.
They need concrete information and not too much technical language. It
is best to explain simply and then try to make the child’s life as normal as
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Concurrent Substance Use and Mental Health Disorders
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35

possible. After explaining the problem, you can make the child feel better
3. It is not the child’s responsibility to make the ill person well.
if you move on to do something special that the child enjoys.
Children need to know that the adults in the family, and other people,
such as doctors, are working to help the person. It is the adults’ job to
S C H O O L - A G E D C H I L D R E N
look after the person with the problem.
School-aged children can handle more information than younger
children. However, they may not understand details about medications
Children need the well parent and other trusted adults to shield them
and therapies.
from the effects of the person’s symptoms. It is very hard for children
to see their parents distressed or in emotional pain. Talking with some-
T E E N A G E R S
one who understands the situation can help sort out the child’s confused
Teenagers can generally manage most information. Often, they need to
feelings.
talk about their thoughts and feelings. Teenagers worry a lot about what
other people, especially their peers, think of themselves and their families.
They may ask about genetics. They may also wonder how much
Outside the home
they should tell others. They may fear prejudice about mental illness or
substance use problems. Sharing information encourages them to talk.
Many children are scared by the changes they see in a family member
with concurrent disorders. They miss the time they used to spend with
this person. Having activities outside the home helps, because children
What to tell children
are exposed to other healthy relationships. As the person recovers, he or
she will gradually return to family activities. This can then help mend the
It is helpful to tell the children about three main areas:
relationship between the children and the ill family member.
1. The family member has a problem called “concurrent disorders.” The
Parents should talk with the children about what to say to people outside
parent or family member behaves this way because he or she is sick. The
the family. Support from friends is important. However, concurrent
illness may have symptoms that cause the person’s mood or behaviour to
disorders can be hard to explain, and some families are concerned that:
change in unpredictable ways.
• other people will not understand
2. The child did not cause the problems. Children need reassurance that
• other people may act in a way that is prejudiced toward the person
they did not make the parent or family member sad, angry or happy.
with concurrent disorders.
They need to be told that their behaviour did not cause their parent’s
emotions or behaviour. Children think in concrete terms. If a parent or
Each family must choose how open it wants to be.
family member is sad or angry, children can easily feel they did something
to cause this, and then feel guilty.
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During illness
ON-LINE RESOURCES
Children’s everyday activities can be noisy. Some people who have
concurrent disorders may not be able to tolerate children’s noise and
General concurrent disorders
behaviour. Family members may need to protect an ill parent from situa-
tions that may lead him or her to be irritable and abrupt with the
Centre for Addiction and Mental Health
children. At times, children may need to play outside the home. Or the
www.camh.net
parent may need to rest for part of the day in a quiet area of the house.
Health Canada
www.hc-sc.gc.ca/english/search/a-z/a.html
During recovery
Internet Mental Health
www.mentalhealth.com
Once recovered, the parent or other family member can explain his or her
behaviour to the children. He or she may need to plan some special times
Dual Recovery Anonymous
with the children. Such times re-establish the relationship. They reassure
www.draonline.org
the children that the family member is again available and interested
in them.
SAMHSA (Substance Abuse and Mental Health Services Administration)
www.samhsa.gov/centers/clearinghouse/clearinghouses.html
REFERENCES
General mental health
Healy, D. (2002). Psychiatric Drugs Explained (3rd ed.). St. Louis, MO: Churchill
C A N A D A
Livingstone.
Canadian Mental Health Association (CMHA)
www.cmha.ca
Consent & Capacity Board (Ontario)
NOTES
www.ccboard.on.ca
Family Association for Mental Health Everywhere (FAME)
1. Reiger, D.A., Farmer, M.E. & Rae, D.S. (1990). Co-morbidity of mental
www.fame.volnetmmp.net
disorders with alcohol and other drug abuse, Results from the
Epidemiological Catchment Area (ECA) study. Journal of the American
PsychDirect
Medical Association, 264, 2511–2518.
www.psychdirect.com
38
Concurrent Substance Use and Mental Health Disorders
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39

U N I T E D S T A T E S
Schizophrenia
NAMI
www.nami.org
Schizophrenia Society of Canada
www.schizophrenia.ca/
National Institute of Mental Health
www.nimh.nih.gov
Eating Disorders
National Mental Health Information Center (SAMHSA)
www.mentalhealth.org
National Eating Disorder Information Centre
www.nedic.ca/
I N T E R N A T I O N A L
Rethink (UK)
www.rethink.org/
Attention-deﬁcit hyperactivity disorder
National Resource Center on ADHD
Depression
www.help4adhd.org/
Mood Disorders Association of Ontario
www.mooddisorders.on.ca/
General Substance Use
Depression and Bipolar Support Alliance
Al-Anon/Alateen
www.dbsalliance.org/
www.al-anon.alateen.org/
Alcoholics Anonymous
Anxiety
www.aa.org/
Anxiety Disorders Association of America
Narcotics Anonymous
www.adaa.org/AnxietyDisorderInfor/index.cfm
www.orscna.org/
Double Trouble in Recovery
www.doubletroubleinrecovery.org/index.htm
40
Concurrent Substance Use and Mental Health Disorders
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C A N A D A
Alberta Alcohol and Drug Abuse Commission (AADAC)
www.aadac.com/index_ﬂash.htm
U N I T E D S T A T E S
National Institute on Drug Abuse (NIDA)
www.nida.nih.gov/
Center for Substance Abuse Treatment (SAMHSA)
www.samhsa.gov/centers/csat2002/csat_frame.html
Center for Substance Abuse Prevention (SAMHSA)
www.samhsa.gov/centers/csap/csap.html
National Clearinghouse on Alcohol and Drug Information (PrevLine)
www.health.org/
On-line publications
Best Practices: Concurrent Mental Health and Substance Use Disorders
www.hc-sc.gc.ca/hecs-sesc/cds/pdf/concurrentbestpractice.pdf
Report to Congress on the Prevention and Treatment of Co-occurring Substance
Abuse Disorders and Mental Disorders (SAMHSA)
www.samhsa.gov/news/cl_congress2002.html
Medications for Mental Illness (National Institute for Mental Health)
www.nimh.nih.gov/publicat/medmenu.cfm
Expert Consensus Guidelines Series: Guides for Patients and Families
www.psychguides.com/pfg.php
42
Concurrent Substance Use and Mental Health Disorders

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an Information Guide

Document Outline

Contents
Authorship
Introduction
What Are Concurrent Disorders
What Are The Symptoms of Concurrent Disorders?
What Causes Concurrent Disorders?
How Are Concurrent Disorders Treated?
Recovery and Relapse Prevention
How Concurrent Disorders Affect Families
Explaining Concurrent Disorders to Children
References, Notes, Online resources