Substance Abuse and Mental Illness

In this era of community-based treatment and widespread availability of alcohol and other drugs, people with severe mental illnesses (e.g., schizophrenia, schizoaffective disorder, or bipolar disorder) are highly likely to abuse or be dependent on alcohol or other drugs, such as cocaine or marijuana. According to recent epidemiologic studies, approximately 50 percent of people with a diagnosis of severe mental illness also meet lifetime criteria for a diagnosis of substance use disorder.

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Just why individuals who are mentally ill are so prone to abuse alcohol and other drugs is a matter of controversy. Some researchers believe that substance abuse may precipitate mental illness in vulnerable individuals, while others believe that people with psychiatric disorders use alcohol and other drugs in a misguided attempt to alleviate symptoms of their illnesses or side effects from their medications. The evidence is most consistent with a more complex explanation in which well-known risk factors - such as poor cognitive function, anxiety, deficient interpersonal skills, social isolation, poverty, and lack of structured activities - combine to render people with mental illnesses particularly vulnerable to alcohol and drug abuse.

One further point about vulnerability is clear. People with an established mental disorder - probably because they already have one form of brain disorder - appear to be extremely sensitive to the effects of alcohol and other drugs. For example, moderate doses of alcohol, nicotine, or caffeine can induce psychotic symptoms in a person with schizophrenia, and small amounts of marijuana, cocaine, or other drugs can precipitate prolonged psychotic relapses. Accordingly, researchers often recommend abstinence from alcohol and other drugs for people with severe mental illness.

Substance abuse also appears to worsen health and social problems by contributing to poor nutrition, unstable relationships, inability to manage finances, disruptive behavior, and unstable housing. Substance abuse interferes with treatment as well. People with dual diagnoses (severe mental illness and substance disorder) are likely to deny alcohol and drug problems; to be non-compliant with prescribed medications, and to avoid treatment and rehabilitation in general. Perhaps due to their poor treatment compliance and psychosocial instability, people with both mental illness and substance abuse are highly vulnerable to homelessness, hospitalization, and incarceration.

The problems related to combined substance abuse and mental illness pose a substantial burden to the families of people with dual disorders. Surveys show that family members identify substance abuse and its attendant secretiveness, disruptive behavior, and violence as among the behaviors that are most disturbing. Even though relationships are strained by problems related to dual diagnoses, our research shows that families expend a great deal of time and money helping out in a variety of areas, from providing direct care to attempting to structure leisure time and increase participation in treatment. Furthermore, they are often unaware that their relative is abusing drugs or confused about how to respond to substance abuse, so education is greatly needed.

Although people with co-occuring mental illness and substance abuse desperately need help with both problems, the service system's organizational structures and financing mechanisms often provide barriers to obtaining treatment. The crux of the problem is that the mental health and substance abuse treatment systems are parallel and quite separate. Even though the majority of patients in either system have dual diagnoses, involvement in one system typically precludes or limits access to the other. In addition, both systems may attempt to avoid responsibility for clients with complicated problems.

Even when people with dual disorders are able to negotiate access to both treatment systems, they may have difficulty getting appropriate services. Mental health and substance abuse professionals often have different types of training, espouse conflicting philosophies, and use different techniques. For example, mental health professionals often view substance abuse as a symptom or response to mental illness and therefore minimize the need for concurrent substance abuse treatment. Similarly, alcohol and drug treatment professionals often emphasize the role of substance abuse in producing the symptoms of mental illness and therefore discourage active psychiatric treatment. These views can prevent accurate diagnosis and subject the client to a bewildering set of conflicting treatment prescriptions. Because many programs make no attempt to integrate treatment approaches, the client, with impaired cognitive capacity, is entirely responsible for the integration. Not surprisingly, the client often fails in this situation and is considered difficult or labeled as "treatment-resistant."

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Over the past 10 years, programs developed specifically for people with dual disorders have emphasized the importance of integrating mental illness and substance abuse interventions at the level of clinical care. For example, mental health programs for people with severe mental disorders can easily include substance abuse interventions as a core component of comprehensive treatment. Assertive outreach as well as individual, group, and family approaches to substance abuse treatment are incorporated into the comprehensive approach of the case management or mental health treatment teams. Because substance disorder is a chronic illness, treatment typically occurs in stages over several months or years. Clients must first be engaged in outpatient treatment. At this point, they often require motivational interventions to persuade them to pursue abstinence. Once they identify abstinence as a goal, they can use a variety of active treatment strategies to attain abstinence and to prevent relapses.

People with dual diagnoses clearly can be engaged in these programs. Over the short term, their regular participation in outpatient treatment results in decreased institutionalization. Over the long run - approximately two or three years - most people can attain stable abstinence from substance abuse. Because substance abuse is a chronic, relapsing disorder, treatment may take several months or years, and involvement in some form of treatment should continue for many years.

Unfortunately, at this point, integrated treatment programs are not widely available. Most occur as models or demonstrations. Cost is not the limiting factor because a substance abuse specialist can be hired as a member of the mental health treatment team at approximately the same salary as a mental health specialist. But the mental health system must be willing to take responsibility for this critical aspect of clients' lives and must sponsor the appropriate changes in service organization, financing mechanisms, and training. For example, effective integration of mental health and substance abuse treatments often requires cross-training of mental health and substance abuse providers to sensitize them to the philosophies and treatment techniques used in the different fields.

Families can be helpful in several ways: By being aware of the high rate of substance abuse among people who are severely mentally ill, by being alert to signs of alcohol or drug problems, by insisting that the mental health system take responsibility for addressing alcohol and drug problems, by pursuing drug and alcohol education, by participating in alcohol and drug treatments for their relatives, by advocating for the development of dual-diagnosis programs, and by encouraging research into this critical area.

SOURCE: NAMI publication, The Decade of the Brain, Fall, 1994

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