Many people who suffer from a substance addiction also suffer from a mental health problem at the same time and the difficulties they are faced with far outweigh the effects of either alone. Often, only one of the two problems is identified and that depends on the primary problems treated where the diagnosis is given and which problem is most prominent. When one of the problems is severe it may eclipse the other problems the individual is suffering from.
Although one problem may be considered primary and the rest secondary, this does not mean that the individual isn’t experiencing serious problems related to each disorder they are experiencing. To the contrary, when there is a severe mental health or substance use disorder, even mild symptoms of other disorders can be experienced as extremely problematic. This is in part due to the fact that the effects of symptoms of different disorders which co-occur are not additive but multiplicative. This means that the result of the symptoms of two different disorders experienced together is not a function of simply adding the effects of one disorder with the effects of the second. Instead , the symptoms of the different disorders have their own specific effects but also interact with each other such that the symptoms of one may lead to increased problems with the other (Demyttenaere, Bruffaerts, Posada-Villa, Gasquet, Kovess, Lepine, & Chatterji,(2013).
It is also possible that one problem precedes the other and that the second is an attempt to cope with the first. This is most often the case when mental health issues or severe trauma lead a person to use drugs as a coping mechanism. This can occur in two different ways. The individual may experience a physical or psychological trauma which leads to extreme physical or emotional pain. To control the pain doctors may prescribe strong pain medication or any one of a series of drugs used to treat depression anxiety or other mental health disorders which can result as a function of an experienced trauma. The person may become addicted to the medication and fear a relapse of symptoms if they do not continue to take the medication.
When both difficulties are identified, people are ferried back and forth between treatment programs which often provide different or conflicting approaches. It is important to treat co-occurring disorders using an integrated approach within the same program. The only way to successfully treat someone with both types of conditions is to focus on each at the same time. This hybrid approach will decrease the amount of time patents spend in treatment, improve the individual’s functioning in a variety of areas, and enhance their overall quality of life.
According to SAMHSA (2005), screening for comorbid and co-occurring mental health and substance abuse disorders should be considered a best practice. Comprehensive screening of all clients and patients is not universal however. The AC-OK Screen for Co-Occurring Disorders is an easy to understand - easy to administer quick response screening instrument that was created to determine co-morbid mental health, trauma and substance abuse disorders. Two studies were conducted to examine the properties of this screening device. A pilot study was first conducted with 234 subjects and the full scale study was carried out with a far larger population sample of 3,608 subjects. Participants were recruited from mental health centers, substance abuse treatment health care providers and residential programs for individuals with co-occurring disorders. Analyses focused on 1250 subjects who had both a mental health disorder and a substance use disorder.
Severe physical injury is a common type of trauma experience that can lead to posttraumatic stress disorder (PTSD), physical health problems necessitating treatment with pain medications to maintain functional ability and other mental health disorders such as mood disorders and anxiety disorders. While many people with accident related PTSD may begin medication to decrease severe pain or associated symptoms of anxiety or depression, some may go on to develop a substance related disorder due to becoming reliant on the drugs. It is not unusual for pain medication to also improve mood and block negative feelings related to the trauma and memories of the accident. Sometimes the increases sense of positive mood and decreased pain may improve an individual’s ability to cope with common symptoms of the disorder. For example, when others are also involved in the accident and only one lives, that individual often experiences survivor guilt, questioning why they survived when others didn’t or telling themselves they should have died and not one of the others.
Without help, people often find it difficult if not impossible to stop taking their medication. When more than one medication is being used this difficulty increases due to the interaction of the medications and different effects that result in separate tolerance, withdrawal symptoms and concerns. While the physical withdrawal symptoms may be or paramount concern in a person’s mind, it is more often the psychological withdrawal symptoms that are the hardest to get rid of. In particular, the belief that it will be impossible to function without the medication leads to fear of interacting with others, resuming normal activities and taking back on personal responsibilities (Wise & Koob,2013)
Physical injury is prevalent across many types of trauma experiences and can be associated with posttraumatic stress disorder (PTSD) symptoms and physical health effects, including increased medication use. Research indicates that PTSD symptoms may mediate the effects of traumatic injury on physical and health related outcomes. Research has been conducted examining the relationships between injury severity, PTSD and pain and psychiatric medication use in people following a traumatic injury (Briere & Scott, 2012)
Results indicated that PTSD symptoms mediated the relationship between injury severity and use of pain medications. In other words, the relationship between injury severity and pain medication use was not a direct relationship but was accounted for by the development of PTSD (Cody, & Beck, 2014). This mediational effect may indicate that for those with PTSD following a traumatic injury, that the use of pain medication may be relied upon for more than just decreasing the injury related pain. It might also be used to help the individual cope with the distress, anxiety and depression they develop as a function of their PTSD.
Evaluation of Assessment Tools
Addiction Assessment or Screening.
The NIDA Modified ASSIST is screening technique for drug abuse in general outpatient medical environments. It is intended to be a quick screening device a particular strength when working with individuals who are seeking treatment for the first time. Also referred to as the NIDA Quick Screen, the NIDA Assist is an online interactive guided tool which includes a short series of questions. Based on the patient’s answers the tool uses a hierarchical decision tree approach. Therefore, only the questions which are relevant to the patient’s condition are asked. A General Score is generated and this is the basis for recommendations for the degree of intervention to be suggested to the patient. There are also links that give resources that allow practitioners to provide an appropriate referral for treatment. Links also provide questions to determine the best level of care for the patient at the time.
This screening tool provides an easy method for practitioners to determine the needs of patients who are addicted to a variety of substances. With this single device, practitioners can evaluate drug and alcohol use and abuse at different time from lifetime occurrence to current. Other strengths include that the evaluative tool is in the public domain and so it is readily accessible without the need to order it or create scoring protocols. The website provides supplemental materials such as a quick reference guide, scoring information, and administration instructions all in the same place (WHO, 2002).
This screening instrument, a modified version of the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), can be used with those over the age of 17. There are Clinician versions and self-report versions. The availability of two versions provides the flexibility for practitioners to decide which version the patient would be most comfortable completing to provide the most information possible. With only a few questions and decisions trees guiding the Clinician or patient to the next relevant question, the ASSIST ensures the client doesn’t have to answer questions that don’t apply to their situation. In addition, to time frame, associated problems are screened for including general mental health difficulties, the likelihood of future drug use and injecting drug use if not a current problem and the risk of harm resulting from the clients drug use at the time or in the future.
The Mini Neuropsychiatric Interview is a clinician in depth interview which assesses 20 mental disorders including addictions and trauma/PTSD. This comprehensive assessment device takes 15-20 minutes to complete and provides information on symptoms, risk factors, and the likelihood of future harm. The scale has extensive validation information and research has demonstrated it’s validity. For each disorder the Mini has an ordered serious of 15-20 questions which are scored immediately, providing the clinician with information about the clients main problems while still in the room so appropriate follow-up can be conducted. The Mini instruments include the Neuropsychiatric Interview, the most complete tool for assessment of co-occurring disorders, a short version for when there is only limited time but the individual needs to be evaluated, the expanded version which assesses whether mental health problems were experienced exclusively during periods of alcohol or drug abuse or during time of abstinence and a tracking device which is a long format allowing symptoms to be followed and to evaluate whether symptoms change with psychological treatment or medication, and provides a documentation system for recording all information in an organized and logical sequence that can be quickly reviewed before a session.
The best evaluation technique for this case is the second one mentioned, the Mini. This is because this assessment is far more comprehensive than the Assist and provides information on co-occurring disorders including the co-occurrence of mental health disorders and substance use disorders. Additionally, the sequence of onset of symptoms can be evaluated to determine if one disorder trigger the other or if they both occurred at the same time. The way in which co-occurring disorders interact is also evaluated.
References
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Briere, J. N., & Scott, C. (2012). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Sage Publications.
Cody, M. W., & Beck, J. G. (2014). Physical injury, PTSD symptoms, and medication use:
Examination in two trauma types. Journal of traumatic stress, 27(1), 74-81.
Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J., &
Chatterji, S. (2013). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.
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WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening
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Wise, R. A., & Koob, G. F. (2013). The development and maintenance of drug addiction.
