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People who suffer from both mental illness and a substance use disorder often receive care from two very different types of systems, creating confusion for patients, their families and clinicians, says Ken Duckworth, MD, Medical Director for the National Alliance on Mental Illness (NAMI).

“If you have schizophrenia, you are thought to have a condition that you aren’t responsible for, so caregivers organize around trying to help you with medication, jobs, housing and benefits,” says Dr. Duckworth, who is an Assistant Clinical Professor at Harvard University Medical School. “Although substance abuse is a brain-based phenomena, our culture holds you accountable for it—they assume it’s your choice, and your recovery.”

Co-occurring mental illness and substance abuse is one of the issues NAMI is focusing on during Mental Illness Awareness Week, October 7-13.

Finding the best treatment for people with co-occurring disorders is so important because these are some of the highest risk, most vulnerable individuals, Dr. Duckworth notes. According to the Substance Abuse and Mental Health Services Administration, about 8.9 million adults in the U.S. have both a mental and substance use disorder. Only 7.4 percent of individuals receive treatment for both conditions, and 55.8 percent receive no treatment at all.

Dr. Duckworth has seen the conflict between the two care systems when he has sent patients with mental illness to an AA meeting, and they have come back and said they were advised to throw out their lithium. “I do notice that within the culture of AA, there is still some variability in the acceptance of biochemical intervention,” he says. “This is a complicated area, because chemical dependence has caused tremendous suffering. However, I don’t view the use of lithium as chemical dependency.” Some AA groups are completely supportive of medications to treat mental illness, he adds.

He also sees variability in how suboxone is viewed as a treatment for opioid dependence. “Some major substance abuse treatment centers don’t believe in it,” he says. “As a field, we have not come to an agreement on this.”

Dr. Duckworth says more needs to be done to integrate mental health and substance abuse treatment. One critical need is increased training in co-occurring disorders for psychiatry residents. He does see some improvement in this area. “When I was in training, psychiatrists didn’t use AA as a key resource for patients,” he says. “Now, psychiatrists are using AA, NA, Al-Anon and peer resources.”

He sees several other encouraging signs the fields are starting to work together. One is the growing use of peer support in mental health, which grew out of substance abuse treatment. Another is the increasing use of depression screening in substance abuse programs. “We still don’t have a fully integrated service system, but we are better off than we were 10 or 15 years ago,” he commented. “As a field, we’re going in the right direction.”


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