Epidemiological and clinical studies find that psychiatric disorders and substance use disorders (SUDs) are highly comorbid (a condition referred to as “dual” or “co-occurring” disorders). Kessler, Chiu, Demler, Merikangas, and Walters (2005)
report that 27% of people have at least one psychiatric disorder, and 45% of people with psychiatric conditions actually have two or more disorders. SUDs are highly comorbid with borderline and antisocial personality disorders, bipolar, psychotic, depression, and anxiety disorders. Other important epidemiological findings are a strong comorbid association between social anxiety disorder and cannabis use disorder (Kessler et al.). This is especially significant because social anxiety disorder and cannabis use disorder often onset in adolescence.
The rate of comorbidity of psychiatric and SUDs in clinical samples is much higher. Sheidow, McCart, Zajac, and Davis (2012)
report that 36% to 40% of young adults with a serious mental health condition or young adults seeking treatment meet criteria for a SUD. Severity is also higher among patients with comorbid disorders. Moss, Chen, and Yi (2012)
used the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) data and reported that “chronic severe” people, the most severe alcohol dependent people in their sample, consistently score lowest on a measure of mental adjustment compared to their less severe counterparts. Among adolescents in treatment studies, more than 60% have comorbid substance use and non-SUD with more than 50% having a conduct disorder and 15% having major depression or attention-deficit/hyperactivity disorder (ADHD; Grella, Hser, Joshi, & Rounds-Bryant et al., 2001
). It is logical that the presence of comorbid disorders indicates a need for the simultaneous treatment of both conditions, sometimes referred to as integrated treatment of dual disorders. Orford (2008)
and others have recently called for the need to recognize addiction as a multiply determined disorder that cannot be adequately treated by applying the narrow biomedical model of prescribing one medication or one psychosocial treatment. The presence of co-occurring conditions increases severity and complicates recovery (Daley & Moss, 2002
; Grella et al., 2001
), and a natural outgrowth of increased severity has been a greater use of integrated treatment, compared to separate treatment of combined conditions (Baigent, 2012
; Torrens, Fonseca, Mateu, & Farre, 2012). The logic for use of integrated treatment is that multiple approaches will be more comprehensive in treating a condition that is really an interaction of disorders. Furthermore, treatment in one facility by multiple clinicians allows for continuous communication and more accurate recommendations for particular clients. Integrated treatment
refers to the focus of treatment on two or more conditions and to the use of multiple treatments such as the combination of psychotherapy and pharmacotherapy. Findings related to an integrated treatment approach versus single focused treatments are robust for demonstrating the superiority of the integrated approach (Baker, Hides, & Lubman, 2010
; Mangrum, Spence, & Lopez, 2006
; Mueser, Noordsy, Fox, & Wolfe, 2003
; van der Bosch & Vereul, 2007
; Ziedonis, 2004
Integrated treatment of dual disorders often involves an interdisciplinary team, including social workers in various roles, such as psychotherapists, student counselors, and case managers. Social workers are often at the forefront of every mode of treatment that focuses on the services critical to the reduction of substance abuse and mental impairment. It is important for social workers to understand how comorbid disorders interact because social workers often work directly with substance abusers in residential settings and with hospitalized mental health patients and are the health care workers most likely to be responsible for patient discharge planning. Similarly, more than any other profession, social workers perform case management duties for comorbid clients in the community. Lastly, social workers who are in direct practice with mental health clients who abuse substances in outpatient care can benefit from an understanding of how comorbidity increases severity of all conditions and, thereby, compromises recovery and risk for relapse.
This article focuses on a review of the risks for developing comorbid disorders and how their interaction operates to exacerbate the symptoms and behaviors associated with each. We also present information on the need for higher intensity treatments for comorbid clients and the combinations of treatments that appear to be most effective for clients with particular comorbid disorders.