As our field continues to mature, increased emphasis is being placed on the complex issues involved in diagnosis and treatment of co-occurring disorders. A key factor fueling this trend is the emergence of a biopsychosocial model of treatment, which recognizes substance abuse as a brain disease, with clear biochemical, genetic, psychological and social-environmental determinants (Gorski; Brick and Erikson, 1999).

By definition, a co-occurring disorder entails the presence of both a severe mental illness and a substance use disorder. An appreciation of the prevalence of co-occurring disorders among the general population can be garnered from the following statistics (Madrona Institute, 2006):

• 4.2 million adults age 18 and older have a serious mental illness (SMI) and a substance abuse disorder.
• Illicit drug use is more than twice as high among persons with a SMI than without (27 percent vs. 12.5 percent).
• 20 percent of persons with substance use disorders have at least one mood disorder; 18 percent have at least one anxiety disorder.
• 29 percent of persons with a current alcohol use disorder and 48 percent of those with a drug use disorder have at least one personality disorder.
• Between one-half and three-quarters of incarcerated youth suffer from a mental health disorder; more than half of this population has substance abuse problems.
• Surprisingly, over 80 percent of persons with co-occurring disorders do not perceive a need for treatment.

Historically, chemical dependency and mental health treatment in the United States have entailed markedly different philosophical and clinical orientations. Consequently, treatment programs addressing these two classes of disorders have been largely separated from one other. The chemical dependency treatment model places heavy reliance on a peer counselor model and the spiritual aspects of recovery and self-help; and tends to view psychopathology as secondary to addiction. The mental health services model, by contrast, employs a medical/professional model; places major emphasis on scientifically based treatment, one on one therapy by licensed professionals, and treatment via medication; and tends to view substance use as secondary to psychopathology (Madrona Institute, 2006).

The emerging biopsychosocial treatment model provides a basis for promoting a more holistic, integrative approach to treating patients with co-occurring disorders. Parallels between chemical dependency and major mental illness, when viewed under the bio-psychosocial model, include: both groups of illnesses can be viewed as brain diseases with definite bio-chemical determinants; genetic predisposition plays a significant role in the etiology of both classes of disorders; and both chemical dependency and serious mental illness tend to be viewed as chronic diseases which, while essentially incurable, can be brought into stabilization and remission via appropriate treatment (Madrona Institute, 2006).

Diagnostic issues in co-occurring disorders

Given the historical separation of chemical dependency and mental health services, combined with distinct ideological differences between the two groups of disciplines, establishing an accurate diagnosis and integrated treatment plan for an individual suspected of suffering from two or more co-occurring disorders can be fraught with challenges.  

Diagnosis of co-occurring disorders in early recovery is particularly challenging, due to the presence of the Post Acute Withdrawal Syndrome (PAW). During the post-acute withdrawal stage, which can run anywhere from six to18 months following detoxification, the newly recovering person’s mind and body are extremely vulnerable. During PAW the person’s body — especially the brain — goes through an intensive readjustment process, attempting to learn how to resume normal functioning without alcohol or drugs. Common symptoms during post-acute withdrawal include: severe anxiety and confusion, depression, difficulty in concentrating, extreme irritability, and excessive vulnerability to stressful situations (Gorski, 1989).  

Consequently, establishing an accurate diagnosis of co-occurring disorders during early recovery is often difficult, as many of the symptoms of PAW mimic various psychiatric disorders including: anxiety disorder, major depression, bipolar disorder and various personality disorders. This is complicated by the presence of serious nutritional imbalances that occur in many recovering alcoholics and addicts. Addictions professionals are well aware that patients with a history of alcohol and/or drug abuse typically develop heavy cravings for refined sugar and caffeine as they recover. The concomitant episodes of depression, irritability, mental confusion and disturbing moods swings observed in these patients are often attributable to wide blood sugar fluctuations triggered by excessive consumption of sugar and caffeine, combined with depleted levels of B vitamins, calcium, magnesium and zinc, which adversely affect the central nervous system (Ketcham and Mueller, 1983).

Additional complications in establishing an accurate diagnosis of co-occurring disorders are addressed in recent testimony from credible sources regarding the potential overdiagnosis of bipolar disorders (NIMH, 2007; Hutto, 2001; Ayers, 2006). A press release from the National Institutes of Mental Health (NIMH), dated Sept. 3, 2007, highlights study findings published in the Archives of General Psychiatry, documenting that the diagnosis of bipolar disorder among children and adolescents has increased by 40 times over the past decade. During this same period, the rate of diagnosis of bipolar disorder among adult patients has practically doubled. One of the study’s principal investigators, Mark Olfson, MD, MPH, of the New York State Psychiatric Institute of Columbia University, states, “It is likely that this impressive increase reflects a recent tendency to overdiagnose bipolar disorder in young people, a correction of historical under recognition, or a combination of these trends.”  

Ayers points out that adolescents are often perceived as highly reactive and moody, as a reflection of significant emotional distress and social vulnerability that often accompanies the adolescent developmental process. However, these developmentally related mood swings, which can be exacerbated if the adolescent is using drugs or alcohol, do not in and of themselves constitute evidence of bipolar disorder.  Commenting on potential risks posed to the patient by an incorrect diagnosis of bipolar disorder, Ayers reports that these can include: delay in obtaining proper treatment; unnecessary use of medication with significant side effects; worsening of the patient’s symptoms; and placement of a stigmatizing label on the patient (Ayers, 2006).

By now it should be apparent that establishing an accurate diagnosis of a pattern of co-occurring disorders can be highly problematic. Due in part to the difficulty in establishing an accurate psychiatric diagnosis during early sobriety, addictions professionals have historically recommended that all psychiatric evaluation be deferred until the patient has been clean and sober for at least six months. While this may be sound advice in some situations, whenever it is suspected that a major psychiatric disorder may be present, the patient should promptly receive a thorough psychiatric evaluation by a clinician who is also familiar with addictive disorders. This is true irrespective as to how long the patient has been abstinent from drugs and alcohol, and is especially true whenever the presence of serious suicidal ideation is suspected.

Treatment considerations

Once a diagnosis entailing the presence of co-occurring substance abuse and psychiatric disorders had been established, the patient requires an integrative, multi-disciplinary approach to treatment, designed to address both sets of issues. This, in turn, necessitates that the entire treatment team consciously work together to surmount the barriers that have historically impeded collaboration between the addictions and mental health disciplines. Above all else, this integrative approach must be provided within the context of a compassionate, holistic treatment orientation, which fully respects the intrinsic dignity and worthiness of each patient.

Arriving at an appropriate blending of the substance abuse and psychiatric dimensions of treatment can entail a rather delicate balance. For example, substance abuse patients who suffer from co-occurring disorders are often overwhelmed when an overly psychoanalytical approach is employed on the mental health side during the early stages of recovery.  

Conversely, patients who have co-occurring disorders will experience less than optimal treatment outcomes if their psychiatric issues are either minimized or ignored. This may occur, for example, if the patient is subjected to an overly rigid “old-line” approach on the addictions side of treatment. Likewise, a patient with an obvious need for psychotropic medication may suffer serious harm if he or she links up with a 12-step sponsor who adamantly insists that all mind-altering medications must be avoided.  

Whenever possible, patients requiring medication for psychiatric stabilization should be referred to “Double Trudgers” meetings. This is a special type of Alcoholics Anonymous (AA) meeting, designed to provide effective self-help support for patients in recovery from substance abuse, who also require medication to assist in their recovery from pressing psychiatric issues (Meisler, 2001).

Psychiatric stabilization constitutes an important component of treatment for patients with co-occurring disorders. Stabilization via administration of appropriate medications, accompanied by a sound integration of problem-focused psychotherapy and recovery-focused counseling, can be effectively accomplished on an outpatient basis for many patients. For patients presenting more complex psychiatric issues, and/or a heightened sensitivity to psychotropic medication, referral to a hospital-based short stay stabilization program may be indicated. This can yield both a clinically efficacious and cost-effective approach to this component of treatment. This is particularly true if these services are rendered in a compassionate environment by staff who are sensitive to the special needs and challenges posed by chemically-dependent patients who also present with significant psychiatric issues.

Wellness considerations in treating co-occurring disorders

From a wellness perspective, in crafting an integrative treatment plan for a patient with co-occurring disorders, it is critically important that both addictions treatment and mental health staff be sensitized to the fact that these patients are at risk of facing a “double whammy” in terms of stigmatization. Accordingly, it is imperative that treatment staff bend over backwards to treat these patients as whole persons, with utmost respect and dignity. Staff who are themselves in recovery from co-occurring disorders, can serve as effective role models in relating to this special patient population.
I firmly believe that treatment outcomes and overall quality of life for patients suffering from co-occurring disorders can be dramatically enhanced if a wellness orientation is effectively blended into all phases of treatment. The following suggestions relate to specific applications of wellness and recovery principles in treating co-occurring disorders patients.

• Nutritional Considerations: As is the case with all patients entering recovery, it is essential that co-occurring disorders patients receive guidance on transitioning to a well-balanced diet, to help repair damage to the central nervous system and other bodily systems stemming from years of excessive drinking and/or drug use. Optimal nutrition helps strengthen the neurotransmitters, promoting a more favorable balance in brain chemistry. Among other things, quality protein, together with foods rich in B vitamins and omega-3 fatty acids (wild salmon is an excellent source), play an important role in promoting normal functioning of the central nervous system.    

As discussed previously, curbing excessive consumption of both sugar and caffeine is critically important in stabilizing the mood swings that often occur in early recovery. This is especially true with patients who have co-occurring disorders.  

A word of caution is in order concerning the tendency of some patients to self-medicate via over the counter nutritional supplements. St. John’s Wort and Sam-e are promoted by distributors as natural agents for combating depression, while kava kava and other supplements are likewise promoted as anti-anxiety agents. From a clinical perspective, I believe that use of supplements with mind-altering potential, in conjunction with psychotropic medication, requires pre-approval and careful monitoring by a qualified medical professional. While appropriate use of these supplements may be helpful in some situations, self-medication is fraught with danger, as these substances may potentiate the effects of the patient’s prescribed medication. Likewise, treatment professionals need to be alert to the tendency of some patients to rationalize discontinuing their medication on the grounds that they are taking supplements with purported psychotropic properties.

• Exercise: I highly recommend regular vigorous exercise for all patients in recovery, provided that appropriate medical clearance is obtained. It is well known that exercise promotes overall health and vitality, and plays an important role in safeguarding against cardiovascular disease, strengthening our immune systems, reducing stress and promoting increased self-esteem. The latter item can be especially beneficial to patients in recovery from co-occurring disorders, as they develop an improved self image through taking a very proactive step toward taking charge of their health and their lives. Exercise can also play an important adjunctive role in combating both depression and anxiety through the production of endorphins — natural chemicals produced by the body that trigger the pleasure center of the brain — while concurrently promoting a sensation of calmness and well-being.

• Weight Management: A frustrating side effect that sometimes accompanies use of psychotropic medication, particularly some of the antipsychotics, is that these drugs sometimes promote involuntary weight gain. This underscores the importance of supporting patients with co-occurring disorders in following a balanced pattern of nutritional intake, based around appropriate portions of nutrient-dense, whole foods, together with a regular regimen of exercise, appropriate to the patient’s age and going-in level of fitness.  
 

Encouraging these patients to bring their diets into balance, while engaging in regular exercise, can play an important role in nurturing the increased confidence that comes from taking charge, and doing whatever they can to minimize both the likelihood and consequences of unwanted weight gain. It is especially important that these patients receive full support in developing healthy body images. In particular, they need to appreciate the fact that one can be physically fit, even if he or she is somewhat above the normal body weight (Weil, 2005). Helping the patient attain an improved level of fitness can be accomplished by enabling the patient to take charge of his or her nutritional intake, via a well balanced diet, while concurrently increasing energy output via exercise.  

• Meditation: Meditation is essentially a natural process of relaxing and quieting our minds by stepping back from the excessive “mind chatter” that we bombard ourselves with throughout the day. Some of the more popular forms of meditation include Transcendental Meditation and similar techniques that employ silent repetition of a “mantra” or neutral word to quiet the mind; various forms of meditation that focus on our breathing; movement meditation, including yoga, tai chi, walking meditation and Sufi dancing; and contemplative prayer (Newport, 2004). In a review of 24 studies that examined potential benefits of meditation in both prevention and treatment of substance abuse, Gelderloos and associates reported that as a group, these studies documented reduced use of alcohol and drugs, increased abstinence, and reduced rates of relapse among subjects who regularly practiced meditation (Gelderloos et. al., 1991).
    

Given the fact the numerous studies by Benson and others document the overall benefits of meditation in promoting a positive state of mental-emotional equilibrium and sense of grounding, it makes sense that many patients with co-occurring disorders might benefit through incorporating one of the many forms of meditation into their overall program of recovery. On a cautionary note, Yorston cautions that persons with underlying psychiatric disorders should consult with a mental health professional before beginning meditation, as there have been rare reports of mania or worsening of other symptoms accompanying the practice of meditation.

• Positive Social Supports: A key reason why AA and other 12-Step programs are effective in helping millions of alcoholics and addicts pursue the path of recovery hinges around these programs’ ability to provide participants with a positive, recovery-focused support system. As previously mentioned, it is often beneficial for recovering alcoholics and addicts who have been prescribed psychotropic medications to attend Double Trudgers meetings, which enable them to interact with supportive role models who are also taking psychotropic medications as part of their overall recovery program.   

It is also important to encourage patients with co-occurring disorders to integrate themselves into mainstream society, in an effort to gain an increased sense of self efficacy and overcome any internally or externally imposed stigmatization regarding their diagnoses. Participating in community-based wellness-oriented activities, such as hiking clubs, biking clubs and fitness centers, can also promote improved self confidence among these patients, together with a reassuring feeling of fitting in.

•Pursuing Central Purpose in Life: All patients need to be actively encouraged to develop their potential to the fullest. This is especially true for patients with co-occurring disorders. Indeed, many people suffering from psychiatric disorders have made invaluable contributions to the world through functioning as highly skilled psychotherapists, leaving their mark in other areas of professional endeavor, or enhancing our overall quality of life through pursuing their own unique pathways as highly gifted artists, writers and musicians.

• Combating Nicotine Addiction: In The Wellness-Recovery Connec-tion, I emphasize that nicotine addiction is the leading cause of death among people in recovery, due to the fact that many, if not most, recovering alcoholics and addicts carry this addiction over into their recovery. This is particularly true for patients with co-occurring disorders. A study based in Finland, published in 1997, focused on the prevalence and determinants of smoking among 1,217 patients in treatment for various forms of psychiatric disorders. The prevalence of smoking was significantly higher in male patients (67 percent vs. 34 percent) and female patients (40 percent vs. 22 percent), when compared with the general population.  Key determinants of smoking in the study population were use of alcohol, poor financial circumstances and male gender (Tanskanen et. al., 1997).
    

Addictions professionals are well aware of the fact that many, if not most, substance abuse patients are not ready to give up smoking when they initially enter recovery. I firmly believe, however, that these patients need to be exposed to the hazards of tobacco during primary treatment, and that they should be strongly encouraged to commit to giving up smoking sometime during their first 18 months of sobriety. This is especially true with co-occurring disorders patients.  Numerous community resources provide support for smoking cessation, including physicians with familiarity with substance abuse disorders; toll-free tobacco quit lines (the nationwide number that links to local quit lines is 1-800-QUIT NOW); smoking cessation classes conducted by the American Cancer Society, American Lung Association and other sources; and Nicotine Anonymous.

In conclusion, working with patients with co-occurring disorders can be both challenging and highly rewarding. As described above, an integrative, wellness-oriented approach to treating this special population, provided in a compassionate setting, can yield real dividends in promoting sustained sobriety, psychiatric stabilization, and an enhanced sense of dignity and self-worth for these patients. Until next time — to your health! C

John Newport, PhD, is a freelance writer, wellness counselor, speaker and consultant based in Port Townsend, Wash. He is the author of The Wellness — Recovery Connection: Charting our Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction. To contact him or obtain more information on wellness and recovery, visit his website at wellnessandrecovery.com

References

Ayers, David (2006). Diagnosis and Over-Diagnosing Bipolar Disorder in America. Main Line Health (web posting  www.mainlinehealth.org).
Benson, Herbert (1996). Timeless Healing. New York: Scribner.
Brick, John and Erickson, Carlton K. (1999). Drugs, the Brain and Behavior: The Pharmacology of Abuse and Dependence. New York: The Hawthorne Medical Press.
Gelderloos, Paul, et.al. (1991). Effectiveness of the Transcendental Meditation Program  in Preventing and Treating Substance Abuse: A Review. The International Journal of Addictions, Vol. 26, No.3: 293-325.
Gorski, Terence T. (1989). Passages Through Recovery: An Action Plan for Preventing Relapse. Center City, MN: Hazelden.
Hutto, Burton (2001). Letter to Editor: Potential Overdiagnosis of Bipolar Disorder. Psychiatric Services, 52:687.
Ketcham, Katherine, and Mueller, L. Ann (1983). Eating Right to Live Sober: A Comprehensive Guide to Alcoholism and Nutrition. Madrona Publishers.
Madrona Institute of Washington. Conference on Effective Treatment for Co-Occurring Substance Abuse & Mental Health Disorders.  October 2, 2006, Port Hadlock, WA.
Meisler, Andy. TELEVISION/RADIO: The Reality of Recovery, Unadorned. New York Times, July 15, 2001.
National Institute of Mental Health. Rates of Bipolar Diagnosis in Youth Rapidly Climbing, Treatment Patterns Similar to Adults. Press Release, September 3, 2007.
Newport, John (2004). The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction. Deerfield Beach, FL: Health Communications, Inc.
Tanskanen, Antti, et.al. (1997). Smoking Among Psychiatric Patients. European Journal of Psychiatry, Vol. 11, No. 3:179-188.
Weil, Andrew (2005). Healthy Aging: A Lifelong Guide to Your Physical and Spiritual Well-Being. New York: Alfred A. Knopf.
Yorston, G.A. (2001). Mania Precipitated by Meditation: a Case Report and Literature Review. Mental Health, Religion and Culture, Vol. 4, No. 2: 209-213.

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