Co-Occurring Disorders and Behavioral Health Services

• Jasmina Vuksanovic

Co-Occurring Disorders and Behavioral Health Services

Co-occurring disorders exist “when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder.”¹ It has also been defined as the co-occurrence of “two or more psychiatric disorders.”² Depending on the disorders involved, comorbidity may be homotypic, which involves disorders from the same diagnostic group, such as alcohol use and drug use, or heterotypic, which involves disorders from different diagnostic groups, such as alcohol use and depression.²

Prevalence and Demographic Factors

Major depressive disorder (MDD) is one of the most prevalent mental disorders in the United States, affecting approximately 6.7% of U.S adults each year.³ Alcohol use disorder (AUD), defined as both alcoholism and harmful drinking, is also prevalent in the United States and often co-occurs with MDD. AUD affects approximately 17 million Americans each year.⁴

Although research has not established a definitive etiological risk factor for both MDD and AUD, there are several proposed theories as to the association between these two disorders. Studies have shown that depressive symptoms may emerge during periods of heavy drinking and withdrawal.⁵ Continued heavy alcohol use may be a precursor to stressful life events, which in turn increases the risk of depression.⁵ Conversely, individuals battling depression are likely to drink heavily in order to cope with the depression, which in turn increases the risk of developing AUD.⁵ Among those with AUD, women have higher depression than men, as do Whites, compared to racial and/or ethnic minorities.⁵ In the general population, alcohol dependent men have a 24.3% lifetime prevalence of major depression, whereas alcohol dependent women have a 48.5% lifetime prevalence of major depression.⁵ In clinical samples, the lifetime rates of co-occurrence for women range from 50% to 70%.⁵ Co-occurrence of AUD and MDD is also associated with increased morbidity, mortality, functional impairment, and risk of suicide.⁶

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Another co-occurring disorder of interest is schizophrenia and substance use disorder. Schizophrenia is a chronic illness associated with hallucinations and disorganized behavior, while the most common substances of abuse are alcohol, cannabis, and cocaine.¹ Schizophrenia affects approximately 1% of Americans, and approximately 50% of individuals diagnosed with schizophrenia also suffer from a co-occurring substance use disorder.⁷ When compared to individuals who suffer from schizophrenia only, dually diagnosed individuals have lower adherence to treatment, increased risk of HIV, higher hospitalization rates, are more prone to violent behavior, and are more likely to commit suicide.⁷ Schizophrenia runs in the family. If one parent has schizophrenia, the risk of a child developing the disorder is 13%; if both parents have schizophrenia, the risk increases to 46%.⁸ Schizophrenia does not discriminate and affects men and women equally. Symptoms often begin between the ages of 16 and 30 and does not commonly occur in children or adults older than 45 years.⁸ Additionally, individuals diagnosed with schizophrenia and a substance use disorder often experience onset earlier in their life than do those who suffer from schizophrenia only.⁸

Service Delivery Barriers and Strategies to Overcome These Barriers

The fragmented health care system poses a huge barrier for individuals seeking care for co-occurring disorders. Due to this fragmentation, patients are not able to receive comprehensive and coordinated care for addiction services and mental health care. Of those struggling with co-occurring disorders, “8.5 % of individuals receive treatment for both disorders; 38.4 % receive treatment for one or the other disorder; and 53 % receive no treatment at all.”¹ One strategy for overcoming this barrier is by integrating mental and physical health care delivery. Combining mental and physical health funds to pay for services would not only increase access to coordinated care, but it would streamline the coding and billing process through the use of common codes. It would also create a network of mental and physical health providers, who would all be responsible for well-being of each patient, thus encouraging coordinated care.

A second barrier is the stigma associated with mental illness, which impedes help seeking. This barrier can be combated by educating patients about the resources available for treatment and the overall importance of a healthy mind and body. Businesses should do more to educate employees about mental health benefits, as many may not be familiar with them. Establishing behavioral health clinics, such as the WestBridge Clinic, would provide the compassionate care many individuals with co-occurring disorders are in need of and would likely encourage these individuals to seek treatment.

A third barrier is one that is faced by Medicare patients as same day separate billing for mental health and medical care is not covered under Medicare.”¹ With the oncoming demographic shift, this segment of the population cannot be ignored. Though this is a more difficult barrier to overcome, policy changes should be made to ensure the elderly have access to mental health services in the primary care setting. Increasing the scope of practice for clinical staff may be a feasible strategy for overcoming this barrier.

Implications for Behavioral Health

Throughout this course we have learned that organizational leaders and clinical staff must exhibit a certain level of commitment to providing quality care in order to effectively treat dually diagnosed individuals. As we see look at Accountable Care Organizations, the benefits of coordinated care become even more apparent. The ACA shifts the focus to evidence-based practices, which will become integral for more effective treatment and improvement in service delivery of co-occurring disorders. Adequate screening methods and health assessments by primary care providers are the first step in the treatment and recovery process¹ and will undoubtedly lead to improved detection rates and treatment of dually diagnosed individuals. It is essential for clinicians to understand the epidemiology of all disorders a person is suffering from to ensure correct and effective treatment is received. Service delivery can be expected to improve with an increase in more knowledgeable clinical staff. Clinicians must be knowledgeable about possible interaction of the two disorders and how both can be treated, rather than just one. However, as long as stigma continues to surround the topic of mental health, there will continue to be hesitation by mentally ill individuals to seek treatment. As a society, we must take the necessary steps and encourage help seeking by those suffering from a mental illness. 

References

1. Levin BL, Hennessy KD, Petrila J (Eds.).Mental Health Services: A Public Health Perspective, Third Edition.New York: Oxford University Press; 2010.
2. Falk D, Yi H, Hiller-Sturmhofel S. An epidemiologic analysis of co-occurring alcohol and drug use and disorders. Alcohol Research & Health. 2008; 31(2): 100-110.
3. National Institute of Mental Health. Available online at http://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed February 19 2014.
4. National Institute on Alcohol Abuse and Alcoholism. Available online at http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics. Accessed February 19 2014.
5. Conner KR, Pinquart M, Gamble SA. Meta analysis of depression and substance use among individuals with alcohol use disorders. Journal of Substance Abuse Treatment. 2009; 37: 127-137.
6. Riper H, Andersson G, Hunter SB, et al. Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis. Addiction. 2013; 109: 394–406.
7. Green AI, Noordsy DL, Brunette MF, et al. Substance abuse and schizophrenia: Pharmacotherapeutic intervention. Journal of Substance Abuse Treatment. 2008; 34: 61– 71.
8. National Institute of Mental Health. Available online at http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml. Accessed February 19 2014.

QUESTION #3

Is Mental Health a Public Health Issue?

Among U.S. adults age 18 years and older, an estimated 26 percent suffer from a diagnosable mental disorder each year, and for young adults, mental disorders are the leading cause of disability.¹ Mental illness also bears a heavy burned on the global economy. The WHO estimates that 14% of the global disease burden is attributable to mental illness.² Among the twenty most significant causes of disease burden worldwide are depression (3^rd), alcohol use disorder (7^th), bipolar disorder (12^th), schizophrenia (14^th), and substance abuse disorders (20^th).²

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Compared to all health expenditures, mental health and substance abuse expenditures have been decreasing since 1986, and are estimated to account for 6.9% of the nation’s health care expenditures in 2014.³ Mental illness increases the risk of developing a physical illness, communicable and non-communicable disease, and intentional and unintentional injury.² To decrease prevalence of mental illness and its adverse effects on overall health of individuals, it is necessary to integrate mental health service delivery into the nation’s public health system.

The public health system encompasses a broad array of topics, which creates opportunities for integration of mental health services through community education, epidemiologic surveys, health screening and assessment, ensuring adequate access to care, identifying risk factors and determinants of health, focusing on prevention and early intervention, and promoting sharing of information among health care providers.³

Traditionally, mental and physical health have been treated in two separate service delivery systems. However, majority of adults diagnosed with a mental disorder to not seek treatment, and those who do, seek treatment within the primary care sector, rather than a specialty behavioral health care sector.³ Integration of the mental and physical service delivery systems leads to better health outcomes in primary care, home health care, and long-term care setting, as well as increased mental health care access, rates of treatment, improved treatment adherence, enhanced clinical and functional outcomes, and greater cost-effectiveness.³ Among older adults suffering from depression, integration of physical and mental health services has shown a decrease in health care dollars spent on care, improved survival, and improved quality of life.¹Among individuals suffering from substance abuse disorders, integrated care leads to lower “hospitalization rates, inpatient days, emergency room use, and medical costs.”³

One example of an integrated health care delivery system is the Veterans Health Administration, the nation’s largest integrated health care system. Zeiss identified five key reasons for this integration. First, patients prefer to receive mental health care in the same setting as primary care, as they are most familiar and comfortable with their primary care provider.⁴ Second, primary care providers often fail to diagnose or misdiagnose a mental illness, especially in older patients who may have other health conditions.⁴ Integrating care can increase detection and accuracy of diagnosis. Third, patients are more likely to seek treatment for a mental illness when a diagnosis is determined in primary care and when care is available in the primary care setting.⁴ Of importance is the difficulty of primary care referral to mental health providers.⁴ Studies have shown an astounding 75% of patients fail to follow through with the referral and therefore do not get the mental health treatment, whereas 90% receive treatment when it is provided by the primary care provider.⁴ Fourth, integrated care allows for information sharing among providers. Of highest importance is information relating to the patient’s diagnosis and treatment options. It allows both health providers to provide ongoing care and treatment to the patient, without overlap of information, or exchange of misinformation among the providers. Fifth, screening for mental illness in the primary care setting may lead to reduction in the stigmatization of mental illness as it will be viewed as one of many steps of a health assessment provided to all primary care patients.⁴ These findings have been echoed through other studies, as we have learned throughout the course of the semester.

Implications for Behavioral Health

Mental illness affects a significant proportion of the U.S. population and the importance of efficient treatment cannot be understated. Integrating mental health services into the traditional public health delivery system and increasing collaboration and information sharing among providers of different disciplines is a key aspect of delivering holistic care. Through course lectures, reading assignments, and videos, we have learned that populations at higher risk of developing a mental illness are more likely to delay treatment, or not seek treatment at all, receive lower quality care, and have higher rates of co-occurring illness and morbidity. The traditional health care model emphasizes preventive care and early treatment, which must be a primary focus for mental health services as well, in order to keep the population healthy, lower the prevalence of mental illness, and maintain an affordable health care system. The number of mental health facilities and organizations providing mental health services and treatment has decreased from 3,942 in 1990 to 3,130 in 2008,¹ thus the need for integration is essential. In order to create a holistic healthcare system, we must break down the existing barriers between the mental and physical health care delivery sectors.

References

1. Levin BL. Week #3 Lecture: Mental Health Systems.2014. 1-11.
2. Levin BL. Week #2 Lecture: Epidemiologic, Historical, & Legislative Perspectives.2014: 4- 15.
3. Levin BL, Hennessy KD, Petrila J (Eds.).Mental Health Services: A Public Health Perspective, Third Edition.New York: Oxford University Press; 2010.
4. Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system. Journal of Clinical Psychology in Medical Settings. 2008; 15:73–78.