One major challenge I’ve noticed as I have observed people trying to navigate our mental health system is that it’s hard to access care for both addictions/substance problems and mental health problems. It’s as if these two issues are viewed as separate, requiring different types of treatment, care, and resources. If you have a loved one who struggles with substance use problems, you might’ve encountered this challenge, particularly if your loved one is an adolescent.
In the public system in B.C., for example, there are different youth-oriented treatment teams depending on whether the primary problem is a substance use versus mental health disorder. As a result, if your loved one struggles with serious substance use difficulties, they might not qualify for a mental health team, including psychiatry support. Instead, they might receive services from alternative programs, including substance-abuse counselling. If they’re dually diagnosed, they might receive concurrent disorders services, which involve short-term substance use counselling and only limited/short-term psychiatric support.
The frequency and intensity of services might also be mismatched with the seriousness of the problem. Youth with severe polysubstance use problems, for example, often need a combination of therapy, case management services to help with access to community resources, and possibly medication to help treat underlying problems (such as depression, anxiety, ADHD, etc.) that can contribute to ongoing substance use. Unfortunately, these important pieces of the puzzle are often not available or are only available for a short period and in a diluted dose. Clients might receive a limited number of sessions, sessions occurring only biweekly or less frequently, and only sporadic or very short-term psychiatric care, for which they often need to wait for several weeks or months. This understandably reflects how thin health and mental health resources are stretched. I’ve spoken to many public health clinicians who would love to be able to provide more to their clients but can’t due to high caseloads and other work demands.
OK, so back to this idea that mental health and addictions are separate problems. In my opinion, substance use problems are mental health problems, and more comprehensive care is needed. Mental health problems often drive substance use problems, and vice versa. In fact, many if not most people with diagnosable substance use disorder also have another significant mental health problem on top of that (see interesting reports by the Substance Abuse and Mental Health Services Admin in the U.S.: National Survey on Drug Use and Health (NSDUH)). Some commonly co-occurring problems include a history of abuse, neglect, trauma, marginalization/minority stress, and the presence of certain personality traits (such as high impulsivity or sensation seeking) and clinical disorders such as ADHD, depression, anxiety, PTSD, personality disorders, and so forth. People often use substances to cope with distress related to these problems, and specific features/symptoms of these problems (e.g., impulsivity as a feature of ADHD) can increase risk of substance use.
Further, the substance problems often take on a life of their own, causing or exacerbating mental health concerns. People who were never depressed, psychotic or highly anxious before using substances sometimes end up with these problems after substance use becomes a way of life. As an example of this problem, consider the effects of cannabis use among youth. Too often, cannabis use is viewed as a normal rite of passage and as a harmless activity, when in fact, plenty of research suggests that the early use of cannabis interferes with brain development and is associated with psychosis. Once a young person experiences cannabis-induced psychosis, they have about a 1/3 chance of developing a primary psychotic disorder (e.g., schizophrenia) within the next year (Substance-Induced Psychosis in First Episode Programming (PDF). There are probably confounds in this research, in that those who develop a psychotic disorder might already have had pre-psychotic, or “prodromal” symptoms well beforehand. Notwithstanding, given this interplay of substance use and mental health concerns, it seems to me that treating both mental health and addictions could go a long way toward preventing serious impairment among youth and young adults. Therefore, in my opinion, separating the care and treatment of addiction versus mental health problems can hamper the comprehensive mental health support that people struggling with substance use difficulties need. ~Alexander L. Chapman, Ph.D., R.Psych.