Why are mental health disorders and addictions treated separately?

According to statistics from the Centre for Addiction and Mental Health, at least 20% of people with a mental illness also have a substance use problem.

To Peter Selby, chief of the addictions program at the Centre for Addiction and Mental Health, this number is very conservative. Laura Calhoun, provincial medical director of addiction and mental health at Alberta Health Services, agrees. Substance abuse and mental health conditions “come together more often than not,” she says.

Does the addiction cause the mental health disorder, or vice versa? Or are both the result of something else – childhood trauma or life circumstances? It’s a question researchers are still trying to answer.

Evidence is showing, however, that there are patterns. For example, one U.S. study found that those who had been diagnosed with an anxiety disorder were five times as likely to abuse sedatives as those who hadn’t been diagnosed with an anxiety disorders.

Alcohol addiction and depression is the most common combination, with studies showing higher rates of drinking and relapse among people with depression. In many cases, depression can come first and cause people to turn to alcohol for the numbing or euphoric affect. In other cases, depression can be caused by the depressive effect of alcohol, explains Didier Jutras-Aswad, psychiatrist and director of addiction psychiatry at the University of Montreal Hospital Centre. “If depression is present, the prevalence rate for alcohol dependency is doubled, and if alcohol dependency is present, the risk of having depression is doubled,” says Andriy Samokhvalov, a scientist and psychiatrist at CAMH.

Integrated treatment for mental health and addictions has the best outcomes

Tim Ayas, clinical medical director of the Claresholm Centre for Mental Health and Addictions in Alberta, says the thinking used to be that the addiction should be treated before the mental health condition. “The old paradigm used to be get the addiction treated first and then come back and we’ll know how much your mental health symptoms are related to your substance abuse,” explains Ayas.

That doesn’t work so well, however. For example, for those who have post-traumatic stress disorder and addiction, evidence shows treating only one condition can make the other worse. “If you put a patient with trauma into the typical addictions program, which may encourage abstinence, they’ll experience more trauma and flashbacks,” says Wiplove Lamba, a psychiatrist and addictions doctor at St. Michael’s Hospital. “And if you put them in regular trauma treatment, they start using more to cope.”

When it comes to alcohol addiction and depression, a randomized, controlled study found that when patients with both conditions were treated with both an anti-depressant and anti-craving medication, 54% were able to maintain abstinence rate from alcohol. When patients were treated with just the anti-craving drug or just the anti-depressant drug, only 21% and 27.5% of patients in each respective group were able to abstain from alcohol.

Recognizing these issues, over the last decade, “the paradigm of treatment” has been to treat conditions in a “parallel” way, by an addictions specialist and by a mental health specialist, at around the same time, says Ayas. But this “parallel” treatment poses challenges. For the patient, having to tell one’s story multiple times and being required to attend additional appointments in another location make it difficult to stay on a treatment course. Coordinating care across sites can be difficult for health workers too. Providers trained in one discipline may not realize that a treatment for addiction could interact negatively with a treatment for mental health symptoms, or vice versa.

For these reasons, experts have come to see the gold standard of treatment as integrated treatment, where the same provider or team helps patients with their mental health symptoms and addiction at the same time. “When you have an integrated team working on both, that has the best outcomes,” says Ayas.

A 2011 review of dozens of studies found that integrated treatments have the highest success rates when it comes to concurrent mental health and substance abuse condition. These integrated treatments are often adapted on a case-by-case basis, involving, “creative combinations of psychotherapies, behavioral and pharmacological interventions,” the authors write.

The “siloes” of mental health and addictions services across Canada

Despite that the evidence says that addictions and mental health treatments need to be integrated to best treat concurrent disorders, in practice, that’s often not what’s happening.

Some providers are still practising according to the paradigm they trained in 15 years ago. “The last thing I want to hear is that somebody goes to the mental health place and someone tells them to deal with the addiction. They go to the addiction place, and they say deal with mental health issue, but that’s happening,” says Lamba.

Nick Mitchell, senior medical director of Addiction and Mental Health at Alberta Health Services, explains that the separation between addictions and mental health care “is a historical one.” Psychiatric care was incorporated into medical care much earlier, he explains, in the late 1800s to early 1900s, while addictions weren’t seen as conditions that doctors should address until the mid-1990s, and even later. “The medical community used to consider mental health issues ‘brain conditions’ whereas substance use has historically been seen as ‘social conditions,’” he says.

The separate ideological underpinnings for addictions and mental health resulted in most family medicine doctors, specialists in counsellors trained in treating one condition or the other – not both. For the most part, health workers have much more exposure to treating mental health conditions than addictions. As Selby puts it, “mental health is the first cousin of health system and addiction is the fourth cousin twice removed.”

Some institutions have had programs to diagnose and treat multiple mental health and addictions disorders for more than a decade, such as CAMH and the Centennial Centre for Mental Health and Brain Injury in Ponoka, Alberta. For the most part, however, addiction rehabilitation centres and community counselling programs remain housed in different facilities – and even different cities – than mental health treatment centres.

Integrated diagnosis and treatment initiatives slowly emerging

The need for the practice of mental health and addictions treatment to better reflect the evidence is not a newly identified problem. The federal government highlighted the issue in 2002 with a major Health Canada report and many provincial governments have long recognized the need for integration.

On the ground the changes have been “slow and patchy,” according to Selby, but nonetheless promising.

At the federal level, in the last two years, the College of Family Physicians of Canada has required family medicine residents to demonstrate competencies in both mental health as well as identifying and treating substance abuse. While mental health has long been a key focus of family doctors training there is now “more rigour in the evaluation of a resident’s ability to manage patients with substance abuse,” says Pamela Eisener-Parsche, director of academic family medicine at the College. In addition, for family doctors who want to specialize in addictions medicine, the College is currently developing more advanced training and evaluation criteria.

At a provincial level, in Alberta, Laura Calhoun explains that “addiction counselors are being cross-trained to do mental health work and mental health counselors are being cross trained to do addiction work, and where that’s not possible we’re at least working to co-locate mental health and addictions counsellors in geographical locations,” says Calhoun. She estimates the completion of the cross-training will take “another five years before we’re all the way there.”

In Ontario, the Ministry of Health has made integrating mental health and addictions services one of its four goals for its 10-year strategy released in 2011.

One program inspired by the strategy is the Flexible Assertive Community Treatment Teams developed by the Toronto Central Local Health Integration Network. Patients with serious mental illness, often combined with substance abuse, have a main contact they can call by phone or visit in person. This lead then coordinates the person’s access to nurses, social workers, addictions specialists and more, depending on their needs at the time. In the last two years, four of the teams have been launched across the city, explains Lori Lucier, a senior consultant in program development at the LHIN.

In late 2013, CAMH launched an intensive program to target alcohol addiction and depression in particular. In addition to prescribing patients both anti-craving and anti-depressant drugs, health professionals provide counselling on a weekly basis at the CAMH clinic. The pilot project, which was open to 28 patients for a 16-week period saw a 78% retention rate, which “is literally unheard of in this kind of population,” says Samokhvalov, who is leading the program. (Typically, only around 45% of patients with these two conditions complete an alcohol cessation program.) Data regarding drinking levels post-program have yet to be published.

Based on the retention success of the program, the model is currently being scaled up in Ontario. This fall, the North Bay Regional Health Centre, Trillium Health Partners in Mississauga and the Toronto Village Family Health Team in Toronto will offer concurrent treatment of depression and alcohol disorders. Termed the DA VINCI Project, the dual treatment program is being funded by the Council of Academic Hospitals of Ontario and Health Quality Ontario.

Selby notes that while “there’s a lot to be done,” he’s heartened by the increasing co-training, especially for new graduates. “I think our next generation is going to be better equipped.”

As Mitchell sees it, while psychiatric medicine was seen as a brain issue and addictions medicine was seen as a social issue, integration is helping the medical community see both through a wider lens. “The evidence is increasingly showing that [both mental health disorders and addictions] involve similar processes in the brain and involve similar regions in the brain,” he says. “They have overlapping environmental predispositions including early life trauma and they have overlapping genetics.”

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  1. Marina Anastasiadis

    There certainly are underlying issues for the majority of addicts. Mental health issues, complex trauma issues, abandonment, neglect, rejection; the list goes on & on. Tim Fletcher an Addiction Counselor & founder of Finding Freedom based in Winnipeg has been teaching addicts about these life issues for years. This program has been successful in helping addicts & their families heal & make healthier choices.

  2. Mat Rose

    This is not news to any of us who work with populations particularly burdened by mental and addictions (inner-city, aboriginal, refugee, incarcerated, etc.). %featured%Community health centres (the more truly interdisciplinary model that the “medical home” is based on) have long provided an example of how you can train up your primary provider teams to give people access to mental and physical health (including addictions treatment) all in one place, with a trusted group who really know their patients/clients.

    What saddens those of us who work in this setting is the ongoing re-invention of the wheel: rather than bring resources to those of us who are already doing it, or joining in to provide assistance to help those who are providing primary care and would like to expand their teams, new programs are implemented that yet again separate treatment providers and fracture patient care.%featured%

    So, my point is that we don’t need to find “new models”. No, we need to find the models that are currently working to provide good integrated care–like community health centres–and add a deeper layer of knowledge, expertise and collaboration.

    • Robert Olcott

      Kaiser-Permanente reportedly did something along these lines, after some unusual developments in their Obesity Clinic, and later dring the first U.S. CDC/Kaiser ACE (Adverse Childhood Exper-iences) study. A number of trauma-informed care initiatives can be followed on ACEsConnection .com . Robert Wood Johnson foundation funded publication of the Community Resilience Cook-book describing nine U.S. and one Canadian initiative. A program in Oregon (I forget the acronym, CHIC or something) is endeavoring to provide a model that works at providing good integrated care, as well as another in Michigan, noted by Pediatrician Tina Marie Hahn, which is involving a medical school there as well.

  3. Robert C. Olcott

    In over a decade, since Vincent Felitti, M.D. published [in both English and German] “The Origins of Addiction: Evidence from the Adverse Childhood Experiences study” [“Ursprunge des Suchtverhaltens-Evidenzen aus einer Studie zu belastenden Kindheitserfahrungen.”-in Praxis der Kinderpsychologie und Kinderpsychiatrie, 2003 52:547-559], I have yet to find any refutations of his assertions. If any readers know of or find any, I would be grateful to learn of them.
    Furthermore, studies such as are noted in “The relationship between adverse childhood experiences and mental health in adulthood: A systematic literature review.”, would seem to lend credence to the assertions noted in this article. “Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.” would seem to indicate that not only mental health and addiction issues, but physical health problems–warranting the attention of all medical subspecialties, as well as Public Health, Epidemiology, and neuroscience. In the Archives of Internal Medicine, I note: “Adverse Childhood Experiences and self-reported liver disease: new insights into the causal pathway”- Felitti being one of the five co-authors.

  4. Robert C. Olcott

    %featured%Gabor Mate, M.D., of Vancouver, B.C., in his 12 years at that clinic, noted that of ALL his female patients with Addiction issues, also reported some type of Childhood Sexual Abuse. %featured%Fortunately, later this month he will be presenting at a CAMH event in Montreal.

    Vincent Felitti, M.D., noted while working at an Obesity Clinic with Kaiser-Permanente in California, that some of his female patients also reported sexual abuse in childhood. At that time the American Psychiatric Association claimed only 1 in 1.4 million American women experienced incest during childhood. Felitti reportedly wondered why 47 of them were in his southern California office.

  5. annick

    According to a documentary shown at Workman Arts last night , addiction to Oxycontin is an epidemic in the far North.. The work of Nurse-Practioner Mae Katt and the opioid hub s headed by Dr.Samokhvalov were the subject of the evening.
    The Panel discussion was provocative.
    How can oxycontin be so easily accessible to people living in communities only accessible by air ?
    We read daily about the exorbitant price of lettuce and fresh fruits up there but not about the availibility of prescription drugs. Why ? Why ? Why ?

  6. Robert Olcott

    %featured%I just came across an article that makes one more case for dealing with both substance abuse “disorders” and “mental health issues” collaboratively and simultaneously. The article is entitled: “Are we misdiagnosing primary attachment disorder as a substance use disorder?” It was recently written and published by Scott W. Stern, LCSW. Stern notes:

    “Many substance using clients given a primary diagnosis of Substance Use Disorder are slipping through the cracks of the DSM-5 when their drug use is actually symptomatic of attachment and separation issues.”%featured%

    “For many substance abusing clients, their behavior is often symptomatic of co-occurring Attachment Disorder. Clients with a childhood history of an unsuccessful attachment and separation from their primary caregiver often develop Attachment Disorder between infancy and age 3.”

    “(This should not be mistaken for Reactive Attachment Disorder, a rare and much more serious condition in which infants manifest the inability to attach within a caregiver relationship.)”

    “It is not uncommon for those with this disorder to self medicate feelings of anger, grief, loss, etc., with substances. In doing so, the drug becomes a substitute for the good, reliable caregiver they have felt deprived of since childhood. ….”

  7. Robert Olcott

    Perhaps the APA’s refusal to consider Bessel van der Kolk’s [2005] proposed diagnostic construct of “Developmental Trauma”, for inclusion in the DSM-5, as well as appropriate criteria for discerning between a primary diagnosis of Attachment Disorder, and a primary diagnosis of Substance Abuse, and whether they are “co-occurring”…..lead the State of Virginia Medicaid program to cease using the DSM-5 codes, and converting to the ICD-10 (International Classification of Diseases-10th edition).

  8. Janet McAllister

    So do we continue to use the term addictions or is this become a subgroup of mental illness? If that happens, what will happen to addictions in our approach and emphasis on it?

  9. Dr. Peter Selby

    %featured%Although childhood trauma is a risk factor associated with addictions, it is not proven to be causative.

    There are many other variables that moderate the association. The disease of addiction is a primary brain disorder. The fact that it often co-occurs with disorders of thought (psychosis), affect(anxiety, depression, ocd, bipolar), perception and other behavioural disorders doesnt mean that it isnt worthy of its own definition, treatment etc.

    So conclude that all addictions are to self medicate trauma is too reductionist. It is an important factor but not the only one to consider. We need to understand and consider the complex interplay between genes and the epigenetics of these behaviours.%featured%

    A developmental, biopsychosocial determination of addictions probably has more utility because it offers us a whole person approach to people suffering from this fatal condition ( if left untreated)

    Integrated service delivery for addictions in mental health settings is necessary as it is in services treating people with infectious diseases such as HIV/HCV or medical conditions such as liver failure. Moreover, the context ( social, environmental, financial etc) in which the person and the service providers find themselves also contribute to the development and or response to addictions.

    In other words, it aint simple. However, it does mean that we work together to ensure that people experience care in a seemless way that promotes healing and recovery and requires intersectorial collaborations beyond the mental health and addiction sector.

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