Co-occurring mental health disorders and dual diagnoses: best practises, and knowing when to refer to specialists

11th October 2024 / Written by Harbor London

Recognising when a patient requires specialist intervention for co-occurring disorders is critical for effective treatment.

In the realm of mental health treatment, the presence of individuals simultaneously suffering from more than one mental health condition represents a substantial challenge for healthcare professionals. The significance of accurately diagnosing and managing these cases cannot be understated, as they often involve complex interactions between mental health conditions and addictions.

Recent studies highlight the prevalence and complexities associated with treatment for those living with co-occurring conditions. For instance, the comorbidity of severe mental health conditions with substance use disorders is remarkably common around the world, often becoming more of an expectation rather than an exception in the assessment of patients with serious mental health challenges1.

Among younger populations, the prevalence of co-occurring condition varies, but can be as high as 54%, with males more frequently affected2. Affective disorders emerge as the most prevalent psychiatric diagnoses among these individuals. The consequences of such dual diagnoses are profound, encompassing issues like poor medication adherence, physical comorbidities, heightened risks of suicide, aggressive behaviour, and even potential incarceration3.

Recognising and addressing these complex mental health requirements needs a multifaceted, specialist, and expertly informed approach. This blog aims to outline the strategies healthcare professionals can employ to enhance treatment efficacy and patient care for those grappling with multiple conditions. As we explore these dynamics, we will delve into integrated treatment plans as well as the importance of timely and appropriate referrals to specialists, helping to ensure that patients receive the rounded support they need.

 

What are co-occurring mental health disorders and dual diagnoses? Exploring definitions and examples

In the complex psychological landscape, co-occurring mental health disorders occur when an individual experiences conditions simultaneously, often including a combination of mental health and substance use disorders. Common combinations may involve depression and alcohol abuse, or anxiety coupled with an eating disorder.

The terminology used varies by region, subtly affecting diagnosis and treatment approaches. In the United States, for example, “co-occurring mental health disorders” typically refers to any combination of two or more psychiatric conditions concurrently present. In contrast, the term “dual diagnosis” is often reserved for instances where an individual has both a mental health disorder and a substance use disorder. Whereas European healthcare professionals often use “co-occurring disorders” to describe both the coexistence of mental health and substance use disorders and the presence of multiple psychiatric conditions. For clarity and consistency in this discussion, we will use the term “co-occurring disorders” to allow us to address the broader implications of multiple concurrent disorders, without constraint of these different terminological preferences.

 

Underlying factors contributing to co-occurring disorders

The high prevalence of co-occurring mental health conditions does not necessarily mean that one has directly caused the other, even if one appeared first4. There are various neurobiological and psychological links that underpin co-occurring disorders4, as well as a myriad of complexities surrounding this. For example, secondary behaviours (i.e. substance misuse) often serve as coping mechanisms for the primary condition5,6, but drug addiction can also contribute to the development of mental health challanges4.

Therefore, it is clear that the relationship between co-occurring mental health conditions does not necessarily point to a causal direction, but instead to shared risk factors such as genetic/epigenetic vulnerabilities, how addictive substances neurologically impact specific areas of the brain, and environmental influences like stress or trauma4:

Genetics and epigenetics: Studies suggest that 40–60% of susceptibility to substance use disorders is genetically determined7, highlighting the complex interaction between genes and environmental factors8. For example, frequent marijuana use during adolescence is associated with increased risk of psychosis in adulthood9.

Brain impact: Addictive substances and mental illnesses often affect similar brain circuits involved in reward, decision-making, and emotional regulation – the areas of the brain and neurochemical processes that mediate reward, decision making, impulse control, and emotions are thought to be both altered and disrupted through use of addictive substances and in cases of depression, schizophrenia, and other psychiatric disorders4.

Stress or trauma: The exposure to stress is a significant risk factor for both the development of substance use disorders and relapse after periods of recovery4. The response to stress is mediated through the hypothalamic-pituitary-adrenal (HPA) axis, which can affect brain circuits that control motivation4. And HPA axis hyperactivity has been shown to subsequently change dopamine signalling within the brain, which may enhance the reinforcing properties of drugs10.

In treating these complex conditions, it is crucial for healthcare professionals to recognise the interplay of these factors. An integrated treatment approach that considers all underlying and contributing factors is essential for effectively managing co-occurring mental health disorders and improving patient outcomes.

 

The diagnostic challenge: why co-occurring mental health disorders can complicate treatment and recovery

Diagnosing and treating co-occurring mental health disorders, therefore, presents significant challenges that can complicate both patient care and the recovery process. The presence of multiple disorders can obscure the clinical picture, making it difficult to determine which symptoms relate to which disorder. This complexity can lead to diagnostic complications, and treatment plans must be intricately tailored to address these multiple, often intertwined issues.

Furthermore, the stigma surrounding mental health, particularly issues like substance abuse, can severely impact treatment outcomes. This can lead to a lack of understanding and empathy, potentially resulting in sufferers feeling marginalised. This can discourage individuals from seeking help or being open about their symptoms, thereby delaying or obstructing effective treatment.

Reports11 highlight several barriers to effective treatment for those with co-occurring disorders. Individuals facing multiple disadvantages – such as those experiencing homelessness or incarceration – can find it nearly impossible to access adequate support. These populations frequently encounter a mental health system fraught with integrated care challenges, including limited national guidance on treatment and persistent poor practices that hinder the delivery of effective services.

Another significant issue is the organisational failure to sustain integrated service delivery12. This failure limits the resources necessary to address clients’ needs comprehensively, including their substance use behaviours. Moreover, there is often insufficient support for mental health professional training in managing co-occurring disorders. Many clinicians feel unprepared to discuss substance issues effectively, suggesting a critical need for enhanced training programs to equip healthcare providers with the skills to offer empathetic and informed care12.

These systemic issues underscore the need for a concerted effort to improve the coordination of mental health services with specialty substance abuse treatment, ensuring that all individuals receive the holistic and empathetic care they require.

 

Integrated treatment strategies for co-occurring mental health disorders

Adopting integrated treatment approaches for co-occurring mental health disorders is essential in providing comprehensive care that addresses the intricacies of each patient’s condition. This whole-person approach to mental health treatment not only targets the symptoms but also the underlying causes of the conditions, ensuring a more effective and sustainable recovery.

One of the key benefits of an integrated approach is its ability to enhance patient engagement strategies. Tailoring treatment plans to the individual needs of the patient, including personalised care plans and continuous support mechanisms, significantly improves adherence to treatment. Engaged patients are more likely to participate actively in their recovery process, contributing to better outcomes.

Research underscores the effectiveness of combining behavioural treatment best practices with pharmacotherapies. According to a National Institutes of Health article, employing cognitive behavioural therapy enhances interpersonal and coping skills, while pharmacological treatments provide crucial support in managing addictions to opioids, alcohol, and nicotine13. These treatments, when integrated, can substantially boost motivation and functional recovery. But it is also noted that cognitive behavioural therapy and dialectical behaviour therapy alone can be pivotal in managing the emotional and psychological aspects of dual disorders, with exposure therapies and contingency management and motivational incentives providing additional layers of support – all helping to more comprehensively address the various dimensions of disorders13.

By integrating these diverse therapeutic modalities, healthcare professionals can offer a robust framework that caters to each individuals’ complex needs, paving the way for improved long-term health outcomes.

 

When to refer patients with co-occurring mental health disorders to specialists

Recognising when a patient requires specialist intervention for co-occurring disorders is critical for effective treatment. Specific signs that might indicate the need for more specialised care include the persistence of symptoms despite standard treatment, worsening mental health despite intervention, or exhibition of complex behaviours that are beyond the scope of general psychiatric care.

Harbor’s comprehensive treatment approach is tailored to meet the intricate needs of individuals with co-occurring disorders. Unlike conventional methods that might focus solely on symptomatic relief, we delve deeper to uncover and address the underlying causes of mental health issues, ensuring an approach that considers the whole person – a method that significantly enhances the probability of successful long-term recovery.

For GPs, psychiatrists, and psychologists looking to refer patients to a specialist, the process is designed to be seamless and supportive. Professionals can initiate referrals through a dedicated channel that ensures all necessary medical information is securely transferred, facilitating a smooth transition and continuous care. Emphasising this process helps to reassure referring professionals and the families involved of the supportive care these people will receive.

By guiding healthcare professionals on mental health referral guidelines and highlighting the curated, personalised services at Harbor, we aim to foster a collaborative environment that enhances patient outcomes and upholds the highest standards of mental health care.

 

Enhancing outcomes for patients with co-occurring mental health disorders

It’s clear that effective treatment requires a nuanced and integrated approach. The interplay of multiple disorders presents unique challenges but also opportunities for healthcare professionals to significantly improve patient outcomes through tailored interventions and comprehensive care plans.

The role of healthcare providers is paramount in navigating these complexities. As front-line responders to mental health needs, a key ability lies in the ability to recognise the signs of co-occurring disorders and initiate appropriate treatment plans is crucial. It is this expertise and dedication that can make the difference between a patient’s recovery or continued struggle. To further enhance the capability to manage these complex cases, we strongly encourage anyone involved in mental health care to pursue continuing education in mental health. Engaging in specialised mental health training and forming partnerships with facilities that focus on dual disorders can provide additional insights and tools necessary for managing and successfully treating these more challenging clinical scenarios.

 

References

  1. https://pubmed.ncbi.nlm.nih.gov/16961418/
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9955022/
  3. https://pubmed.ncbi.nlm.nih.gov/16961418/
  4. https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/why-there-comorbidity-between-substance-use-disorders-mental-illnesses
  5. https://pubmed.ncbi.nlm.nih.gov/22449766/
  6. https://pubmed.ncbi.nlm.nih.gov/22327950/
  7. https://pubmed.ncbi.nlm.nih.gov/22703173/
  8. https://pubmed.ncbi.nlm.nih.gov/22367454/
  9. https://pubmed.ncbi.nlm.nih.gov/23810133/
  10. https://pubmed.ncbi.nlm.nih.gov/18991954/
  11. https://meam.org.uk/wp-content/uploads/2022/06/Co-occurring-conditions-briefing-FINAL-June-2022.pdf
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417038/#:~:text=Focus%20group%20participants%20identified%20three,and%20diagnostic%20and%20billing%20restrictions.
  13. https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/what-are-treatments-comorbid-substance-use-disorder-mental-health-conditions
Open chat
Hello 👋
Can we help you?