Commentary: Dual Diagnosis: The Status of Treating Co-Occurring Disorders in The U.S.

At least 50 to 75 percent of Americans seeking treatment for a substance abuse problem also have a co-occurring mental health disorder, according to the Center for Substance Abuse Treatment (CSAT). However, training of professionals for treating dual diagnoses in the field is not as frequent as its prevalence among Americans.

To put this into perspective, the lifetime prevalence of individuals with substance abuse or dependence in the general population is 16.7 percent; however, the prevalence is significantly higher among people who suffer from schizophrenia (47 percent), any mood disorder and obsessive/compulsive disorder (both 32 percent) and any anxiety disorder (23 percent).

Given these statistics, Hazelden, the leading addiction and prevention publisher in education, treatment, and behavioral health, and IC&RC (International Certification and Reciprocity Consortium), the world leader in addiction-related credentialing, have joined together to introduce tailored programming, entitled Focus on Integrated Treatment (FIT), addressing this void.

Experts from Dartmouth Medical School and IC&RC discuss below the current state of integrated addiction and mental health treatment and answer common questions about co-occurring disorders.

What exactly is a co-occurring disorder?

Co-occurring disorders, or “dual disorders,” means having both substance use and mental health disorders at the same time. Treating co-occurring disorders is distinctive discipline, which blends the best of mental health and substance abuse treatment into a “third technology,” says Dave Parcher, chair of the IC&RC Co-occurring Disorders Committee. For this reason, there is a specialized co-occurring disorders credential for professionals. IC&RC credentials – the Certified Co-Occurring Disorders Professional (CCDP) and Certified Co-Occurring Disorders Professional Diplomate (CCDPD) – are based on the concept that co-occurring disorders (COD) are more than the sum of their parts.

What do addiction counselors and mental health practitioners need to understand about the treatment of co-occurring disorders?

Only two percent of the 5.6 million adults in the United States who are living with co-occurring substance use and mental health disorders actually receive evidence-based integrated care, due in large part to the lack of professional training on this approach. According to Matthew Merrens, professor of psychiatry at Dartmouth Medical School and the co-director of the Dartmouth Evidence-Based Practices Center, the most effective model of treatment is just that: integrated treatment. Rather than sequential or parallel treatment, integrated treatment involves a single, combined treatment team treating both disorders at the same time and in the same setting. Practitioners, program administrators and government officials need to understand that COD is a third, distinct disorder, Parcher explains. Substance abuse or mental health training alone is not sufficient for dealing with the interaction of both disorders, which are constantly influencing each other.

Why is certification or continuing education in the treatment of co-occurring disorders important for addiction counselors and mental health practitioners?

It is important that both addiction and mental health counselors are proficient in the screening, assessment and treatment of co-occurring disorders. Credentialing advances the treatment of co-ocurring disorders, because it facilitates standardized practice across a wide variety of treatment settings and regulatory environments. Most importantly, it ensures trained, ethical professionals are available to clients, families and communities around the globe.

When looking for training on the treatment of co-occurring disorders, what do clinicians need to know?

Clinicians, at both mental health and addiction centers, need to learn the skills of integrated treatment that are necessary to help their clients attain recovery. For any kind of training, professionals should review the instructors’ experience and credentials, ensure that the format fits a variety of learning styles, and assess the curriculum for appropriate competencies. In particular, learners need to know that training addresses the interaction between the co-occurring disorders.

What are some of the elements needed for a qualified co-occurring disorders treatment program?

First and foremost, staff must demonstrate competency, says Merrens. The following are other essential elements of a qualified co-occurring disorders treatment program:

1. Ongoing training and supervision of clinicians
2. Strong leadership
3. Active, recovery-oriented focus to treatment
4. Community-based treatment, including supported employment, supported education and supported housing
5. Peer recovery and community group programs.

Other important qualities of a program include a clinical supervisor for each unit who has the experience and training for dealing with co-occurring disorders, explains Parcher. As well, knowledge of medications used for both substance abuse and mental disorders is key.

What is the importance of an evidence-based protocol in the treatment of a co-occurring disorder?

Evidence-based practices are validated by many randomized controlled research trials with patients in usual care settings. They are the best treatments available and should be adopted throughout the behavioral health system.

Parcher believes that the growing body of research from around the world is encouraging. It has consistently demonstrated that treatment outcomes are significantly improved when individuals with co-occurring disorders receive integrated treatment.

The Focus on Integrated Treatment interactive, online training program was launched in early 2012. It serves to help addiction treatment and mental health professionals develop the skills necessary to successfully deliver an integrated treatment plan for clients living with a co-occurring substance use and mental health disorder.

Kris Van Hoof-Haines, Executive Director of Media Ventures at Hazelden contributed to this article, in partnership with Matthew Merrens, PhD and Dave Parcher, LCPC, LPCMH, CCS, CCDP-D.

Matthew R. Merrens, PhD, is Visiting Professor of Psychiatry at Dartmouth Medical School and the New Hampshire-Dartmouth Psychiatric Research Center.

Dave Parcher, LCPC, LPCMH, CCS, CCDP-D serves as Executive Director and senior clinical supervisor for an organization providing treatment and prevention services to persons with these co-occurring disorders and provides training seminars for the State Division of Substance Abuse and Mental Health. He serves as the Chair of the IC&RC Co-Occurring Disorders Committee.