Robert W. Johnson BS, AAP
UAB Community Psychiatry Program
REACT Team and Birmingham City Jail
Diversion Project

Defining Co-Occurring Disorders
• Co-Occurring disorder vs. Dual diagnosis
– Co-Occurring disorder is used because consumers often have more than two disorders.
• Co-Occurring disorder typically defined as:
– a) At least one substance disorder plus
– b) At least one major mental disorder (i.e.
Major Depression, Bi-polar mood disorder, any Psychotic disorder) (Axis I)

Co-Occurring Disorders:
Population Estimates:
• Approximately 10 million people in the U.S. have co-occurring substance and mental disorders
(SAMHSA, 1997).
– 10 million Americans affected by two illnesses
– 3 million Americans affected by three illnesses
– 1 million Americans affected by four or more illnesses
• When consumers with other mental disorders are considered, (anxiety disorders, personality disorders) this number increases dramatically.

Co-Occurring Disorders:
Prevalence
National Co-Morbidity Survey
– 52% of those with alcohol disorders at some point in their lifetime also had a history of at least one mental disorder.
– 59% of those with other drug disorders at some point in their lifetime also had a history of at least one mental disorder.
– 84% of those that experienced a lifetime of cooccurrence report that their mental illness symptoms preceded their substance use disorder (Kessler et al,
1994).

Co-Occurring Disorders:
Prevalence
Prevalence of co-occurring disorders is higher in public service systems.

Co-Occurring Disorders:
Risk Factors
• Presence of substance use disorder quadruples the risk of having a cooccurring mental disorder.
• Presence of a mental disorder triples the risk of having a co-occurring substance disorder.
• Persons with any one substance use disorder have an increased risk for another substance disorder.

Co-Occurring Disorders:
Relapse Factors
• The most common cause of mental illness relapse in COD consumers is substance abuse.
Especially when the drug of choice is alcohol, marijuana, or cocaine.
• The most common cause of substance abuse relapse in COD consumers is untreated mental illness (SAMHSA, 1997).
• All mental disorders are consistently more strongly related to dependence than abuse
(Kessler 1996).

Co-Occurring Disorders:
Consumer
With
CODs

Co-Occurring Disorders:
Addressing the Continuum
• Low Psych / Low Substance Abuse
• Low Psych / High Substance Abuse
• High Psych / Low Substance Abuse
• High Psych / High Substance Abuse

High severity
III
Less Severe MH
More Severe SA
IV
More Severe MH
More Severe SA
Low severity
I
Less Severe MH
Less Severe SA
Mental Health
II
More Severe MH
Less Severe SA
High severity

Co-Occurring Disorders:
Forms of Care
• Sequential – This model of service delivery for CODs is the traditional one. A person would receive treatment for their mental health disorder and then, sometime later, might receive a referral to another treatment provider to address their substance disorder or vice versa.

Co-Occurring Disorders:
Forms of Care continued
• This model is unsuccessful, especially if the person has serious and active symptoms in one or both categories of disorder.
• The continuity of care is broken. There is no mechanism in place to address impairments associated with co-morbidity (i.e. Social isolation, impaired vocational capability, poor relationships, ADLs, quality of life, etc.)

Co-Occurring Disorders:
Forms of Care continued
• Parallel – In a parallel model of intervention, the person receives treatment for their mental health disorder from one provider or treatment setting and receives treatment for their substance use disorder from another provider – simultaneously.

Co-Occurring Disorders:
Forms of Care continued
• Burden is placed on the individual to negotiate the two treatment systems and sometimes reconcile, inconsistent treatment recommendations.
• In many cases, people are often engaged in treatment programs simultaneously, with no communication between service providers.
• Historically, this intervention may have consisted of someone seeing a psychiatrist for their mental health while being referred to AA to address their substance abuse.

Co-Occurring Disorders:
Forms of Care continued
• Parallel treatment is difficult for all but the highest functioning subgroup of people with CODs – successful achievement stemming from long term symptom stabilization in one category of their disorders and then addressing the other.
• Being challenged by integrated model of intervention nationwide.

Co-Occurring Disorders:
Forms of Care continued
• Integrated – In this model, treatment of all of the person’s disorders are considered simultaneously, in the same service setting, developed by and delivered by cross trained staff (MH and SA).
• Service providers are completely engaged in the treatment planning for both categories of disorder. Service is typically delivered by a multidisciplinary treatment team which includes mental health and substance abuse professionals.

Co-Occurring Disorders:
Forms of Care continued
• Difficult to find professionals who have experience in both mental health and substance abuse. There is a lack of knowledge stemming from both mental health and substance abuse in regard to the other discipline.
• Requires a paradigm shift from both disciplines.
Treatment providers are finding it difficult to adapt to new modalities of treatment (i.e. Harm reduction).

Co-Occurring Disorders:
Forms of Care continued
• Historically, treatment provision in substance abuse, has been 12 step or abstinence based.
NAMI shows that abstinence based modalities have been ineffective in treating consumers with
CODs.
• Battle for service provision.
– Whose clients are they?
– Who is willing to provide services?

Co-Occurring Disorders:
Bridging the Gap
• Community Action Grant: UAB-CPP Birmingham
• Task Force – Alabama Commissioner of Mental Health &
Mental Retardation
• Development of SCATTC (2002) – Southern Coast
Addiction Technology Transfer Center. Serves Alabama and Florida. Part of the National ATTC Network with a
Unified Mission of:
– Increase knowledge & skills of addiction treatment practitioners.
– Heighten the awareness, knowledge, and skills of all professionals who interface with addiction treatment.
– Foster regional and national alliances among practitioners, researchers, policy makers, funders and consumers.

Co-Occurring Disorders:
Bridging the Gap
• PACT & ACT Teams – Substance Abuse
Specialist position, financially supported by
Alabama Dept. of Mental Health &
Retardation (Addictions).
• The Alabama Council of Community Mental
Health Boards.
• ASADS Conferences: Co-Occurring Tracts
• Criminal Justice and Mental Health Conferences
• Integrated Treatment Substance Study Group
• “Train the Trainers” – Cross training through
SCATTC

Co-Occurring Disorders
Further Readings & Resources
Integrated Treatment for Dual Disorders: A guide to effective practice. Mueser, Noordsy, Drake, and Fox.
Criminal Justice / Mental Health Consensus Project. www.consensusproject.org
Motivational Interviewing, 2 nd Edition: Preparing People for Change. Miller, Rollnick, and Conforti
U.S. Dept of Health and Human Services Substance Abuse & Mental Health Services Administration (SAMHSA) www.samhsa.gov
The National Gains Center (COD and Justice System) www.gainsctr.com
National Alliance for the Mentally Ill (NAMI) www.nami.org
National Addiction Technology Transfer Center Network (ATTC) www.addictioned.org
“Co-Occurring Disorders: A Training Series for Counselors” www.fmhi.usf.edu/cmh/training/ole/ole.html
Southern Coast Addiction Technology Transfer Center (SCATTC)
Joan Leary - SCATTC Project Manager for Alabama
401 Beacon Parkway (UAB Substance Abuse)
Birmingham, AL 35209
(205) 917-3780 Ext. 293 or www.scattc.org
Alabama Alcohol & Drug Abuse Association
P.O. Box 660851
Birmingham, AL 35266-0851
(205) 823-1073 or www.aadaa.org
Dual Diagnosis Recovery Network
1302 Division Street, Suite 100
Nashville, TN 37203
(888) 869-9230 Ext. 208 or www.dualdiagnosis.org