Better, together
Our ongoing challenge treating mental health and addiction
In graduate school, a faculty member once taught me a valuable lesson that had nothing to do with the information in the over priced books I was working from. I was in the middle of preparing for my dissertation when they pulled me aside and asked me the most simple, yet seemingly strange question: “Do you know how to bake?”
Like many people, I surely knew enough to be dangerous; enough to make some cookies or even a cake. But was I a baker? Absolutely not. Intrigued by this question, I asked why and what did that have to do with the context of my dissertation. Their response was one that I recall vividly and have since tried to apply to my life since then. They said, “Baking requires you to follow all the steps or else it doesn’t work. The cake tastes bad. The bread falls. Baking requires being precise and knowing the steps. I want you to go home and bake something and think about how you might be able to apply those skills to your professional life.”
At the time, and as anyone who was “dissertating” would be, I freaked out wondering if there was something I was doing wrong in my process. Was I not following some formula or some recipe that meant my dissertation was going to come out underdone? Turns out, this bit of advice had little to do with my dissertation and much more to do with how too many professionals in our space skip steps or look to the simple solution when real change, change that works, takes time.
This theme, of structural problems, has been something I have been surfacing for years. But like steps that the mental health field has skipped, it seems there is a need for a better understanding of our ingredients that we may wish to revisit. There may not be a better example of this than our ongoing separation of mental health from treating addiction and substance misuse. We see them as separate problems, rarely bringing together comprehensive and integrated solutions that work to provide the best outcomes for the person. But when you look at the evidence it’s pretty clear, treating both simultaneously is the only way to go.
At the most basic level, treating these conditions together makes sense as they often co-occur and can influence each other. The science behind this integrated approach is grounded in several key principles, which are obvious if you or a loved one have experienced either issue or you yourself are a clinician and seen it firsthand from a clinical lens.
Here are a few considerations:
Shared Vulnerability: Mental health and substance use disorders share many common risk factors and vulnerabilities. Things such as genetics and environmental or social influences can contribute to the development of both conditions. By tackling mental health and substance use disorders together, treatment can address shared vulnerabilities and provide more comprehensive care with less hassle. Wouldn’t it be nice to have a clinician or team of clinicians who knew your whole story from the start? A team who could work together on the various angles of what ailed you to provide a seamless treatment plan regardless of your “primary diagnosis?”
Dual Diagnosis: Co-occurring mental health and substance use disorders are frequently seen in clinical practice. The presence of both conditions can complicate treatment outcomes, as each disorder can exacerbate the symptoms and challenges of the other. Treating them in isolation may lead to limited success, making it essential to address both simultaneously to achieve better overall outcomes. In the most recent data from SAMHSA’s National Survey on Drug Use and Health (NSDUH), 13.5 percent of young adults aged 18 to 25 had both a substance use disorder and any mental illness in the past year. And we’ve known for years the data on how over 7 million adults have co-occurring mental health and substance use disorders. Or, how of the over 20 million adults with substance use disorders, 38% also had mental illnesses. Flipping this, of the 42 million adults with mental illness, 18% also had substance use disorders.
Bidirectional Influence: It seems obvious in 2023, but to restate what most of us know, mental health disorders can increase the risk of substance use disorders, and substance use can worsen mental health symptoms. For example, individuals with depression may turn to substances as a coping mechanism, which can lead to addiction. On the other hand, substance misuse can trigger or worsen symptoms of anxiety or depression. By addressing both disorders together, treatment can break the harmful cycle and promote recovery.
What’s so confusing to me is that we know what works. Treating mental health and substance use disorders concurrently is highly effective - the gold standard - and requires an integrated approach that considers the unique needs and challenges of each individual. Integrated treatment combines evidence-based practices from both mental health and addiction fields, ensuring that interventions address both sets of symptoms and support long-term recovery. However, this type of treatment also requires us to revaluate our full continuum of care taking into account things we may have left out when only considering mental health or addiction. A more comprehensive continuum of care should include things like detoxification, stabilization, therapy, medication management, and ongoing support. A more comprehensive approach can help individuals address immediate needs while also focusing on long-term recovery and relapse prevention.
Recently, there was a wonderful article published by our friends at George Mason University on the challenges of overcoming addiction. You can read the whole article here. It got me thinking more about this issue and why we haven’t been able to make more progress bringing these two seemingly inseparable fields together.
Rather than rehash a lot of what I have written before on structural reform and why we should be more integrated, I thought instead I would put a few thoughts down on why things aren’t changing and are stuck the way they are (no matter how wrong this may be).
Stigma and Perception: Mental health has long been stigmatized and misunderstood in society. Remember, it’s not too long ago that we locked people away forever as their treatment, and now still do so for some just in a different way (I am looking at you, prisons/jails). The stigma surrounding mental illness has led to a lack of awareness, empathy, and resources for those seeking help. Substance use disorders have also faced significant stigma, but they have often been viewed through a moral or criminal lens rather than a health perspective. This societal perception has influenced how these disorders are approached and treated in health care making some more open and willing to help than others. Separate.
Fragmented Health Care Systems: Health care systems have traditionally been compartmentalized, with mental health and substance use disorders treated separately from general health care. You thought it was bad with mental health being siloed, factor in addiction treatment on top of that and you see how much worse this gets. This decades long separation has resulted in fragmented services, limited clinical integration, and a lack of coordination between mental health and substance abuse treatment providers. The separation is further codified by the historical differences in the development of specialized treatment systems for mental health and substance use disorders.
Different Treatment Philosophies: When I went through training, we got a bit on substance use disorders, but it felt like something someone else was going to address. Sure, I knew all the diagnoses, treatment options, but truly understanding how to treat these things together was a longer course I wasn’t sure anyone in graduate school was getting as they should. On paper, mental health disorders are often treated through psychotherapy, medication management, and other psychosocial interventions aimed at addressing psychological and emotional well-being. Substance use disorders, on the other hand, have historically focused on abstinence-based approaches, detoxification, and addiction treatment programs that target the physical and behavioral aspects of addiction. We’ve finally begun embracing harm reduction practices, which is a huge step towards keeping people alive, but the approach from depending on where you start, who you see, and more remains different.
Diagnostic Classification: The diagnostic classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), have historically treated mental health and substance use disorders as separate categories. This classification system has contributed to the differentiation in how these disorders are identified, diagnosed, and treated. This also gets codified through payment and policy that wants to pay for or treat the diagnosis and not the outcome.
I go back to the recipe. The ingredients we are using work. Kind of. But imagine if we work to create a recipe that combines all the good stuff and was just so much better all around? I think that many of us should reconsider the recipes we are working from. Continuing to separate mental health from addiction just may be an example of where we simply can’t have our cake and eat it too. Maybe we just need a new cake.