Co-Occurring Disorders and How to Identify Them
Co-occurring disorders refers to when an individual has both a mental health diagnosis and a substance use diagnosis. Members with co-occurring disorders and co-occurring needs respond better when they are offered a whole-person care approach and integrated treatment.
Integrated treatment is the preferred method of treating co-occurring disorders, and is defined as a means of actively combining interventions intended to address substance use and mental health disorders in order to treat both disorders, related problems, and the whole person effectively. ("Substance Use Disorder Treatment for People With Co-Occurring Disorders: TIP 42 (PDF)," Substance Abuse and Mental Health Services Administration, 2020, p. 216.)
In order to identify members who may have co-occurring needs, mental health providers are expected to screen for substance use, and substance use providers are expected to screen for mental health issues. Screening tools are used to identify individuals who may be at increased risk of a specific behavioral health concern, such as depression, anxiety, or a substance use diagnosis. These tools can be administered by staff or self-administered. Generally, screening tools have a scoring guide and are not diagnostic, instead they indicate if further assessment or evaluation would be beneficial to identify potential treatment needs.
Assessment tools are more comprehensive than screening tools, and are administered by staff who are trained and/or qualified to administer them. Assessment tools can assist clinicians in determining an appropriate diagnosis. They can also determine the severity of identified conditions and aid in treatment and discharge plan development. Assessment tools can be used as part of a clinician's assessment process, which may also include psychological evaluations, testing, clinical interviewing, and a comprehensive review of other records or previous treatment experiences.
In order to assist providers in this clinical task, PerformCare created a toolkit of some appropriate screening and assessment tools. If providers identify needs beyond their ability to treat, such as an individual who may need trauma-informed treatment, providers are encouraged to assist members by locating a provider who can address the identified treatment need. As a part of evidence-based substance use treatment, some individuals may need medication-assisted treatment (MAT). Identifying a provider who can offer MAT is essential. Providers can use the PerformCare website provider directory to find an in-network provider or contact Provider Services for assistance.
PerformCare is providing examples of screening and assessment tools at the following links, on documents available for download, making it easy for clinicians to access in their daily practice. Please note that this list is not exhaustive, and there are multiple other screening and assessment tools that can be utilized based on the individual's treatment needs.
Evidence-based treatments for mental health and substance use
The most effective treatment modalities for mental health and substance use diagnoses are known as evidence-based treatments. Evidence-based treatments are those that have been proven to be effective based on data and efficacy. Many treatment options are available to treat the symptoms of mental health and substance use. However, it is highly recommended that providers use evidence-based treatments. Members should have access to treatment providers who offer evidence-based treatments to meet specific treatment needs and concerns. Below you will find a list of some common diagnoses and conditions, and the corresponding evidence-based treatments that are available within the provider network.
Cognitive-behavioral therapy (CBT) is widely used to treat anxiety disorders. There are multiple methods within CBT to effectively treat anxiety. These methods include exposure therapy, which has been found to be the most effective. Exposure therapy involves exposing an individual to the source of anxiety or fear without causing distress or danger, and developing safe and healthy responses to identified stressors. Exposure therapy helps to change the fear response and associations to a particular event or stressor.
Exposure therapy has a variety of modalities that can treat multiple forms of anxiety. These include imaginal, in vivo (in real-life), virtual reality, and interoceptive exposure therapy. CBT is generally completed in an outpatient therapy setting by a therapist specially trained to utilize these and other appropriate methods. Medication may also be used to treat anxiety, and can be prescribed by physicians such as psychiatrists, primary care physicians, or certified registered nurse practitioners (CRNPs). For additional information on this topic: Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence.
Cognitive-behavioral therapy (CBT) is frequently used as an evidence-based treatment for depression. A therapist uses CBT to assist people in identifying how their thoughts can impact their feelings and behaviors and, therefore, change their future responses to situations and handle them more effectively. Essentially, by changing the way we think, we can change the way we feel and respond.
CBT is most often utilized in an outpatient therapy setting by a trained therapist. Another evidence-based treatment, the use of medication, must be prescribed, which is often done by a primary care physician, psychiatrist, or certified registered nurse practitioner (CRNP). For additional information on CBT: Cognitive Behavioral Therapy for Mood Disorders: Efficacy, Moderators and Mediators.
MAT is used to treat opioid use and alcohol use disorder. MAT is often used in conjunction with other therapies, depending on a member’s individual needs. Another form of treatment that has been implemented is contingency management principles.
There are many adjunct evidence-based treatments and programming, such as CBT, motivational interviewing (MI), and dialectic behavior therapy (DBT), that are used individually or in conjunction with MAT. These therapy methods can be used in both residential and outpatient settings to support both substance use- and mental health-related needs. For more details about a variety of research-based behavioral approaches, National Institute on Drug Abuse offers additional information on evidence-based approaches (PDF).
An additional resource, SAMHSA TIP 42 practice guidelines for substance use disorders with co-occurring disorders, is posted on the PerformCare website and is available for all providers.
Trauma-focused cognitive-behavioral therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) are frequently used by trained therapists to support individuals healing from trauma. These treatments can be used individually or in conjunction with therapy for other diagnoses (such as depression, anxiety, or substance use), depending on an individual's needs. Both TF-CBT and EMDR are searchable under our Find a provider directory.