Concurrent Disorders

This article addresses the combined effect of experiencing addiction problems and mental health issues. The combination of mental health problems and substance use problems is known as a concurrent disorder. It can be a challenge to pinpoint which type preceded the other – mental health issues or an addiction problem, but regardless, young people and their families have a complicated, if not long, road to recovery. To this end, professionals working with teens ought to know how to describe a concurrent disorder, how to screen for it, and how to best support their students.

What does it mean to have a concurrent disorder? According to the Mental Health Commission of Canada, one in five Canadians have a mental illness or an addiction problem, with the majority comprising young people 15 to 24 years of age. Over 70 percent of mental health problems arise during childhood and adolescence, while over 60 percent of illicit drug users consist of adolescents and emerging adults. An epidemiological study conducted in the U.S. almost 30 years ago was the first to demonstrate a link between addictions and mental health problems. The Regier et al. (1990) study found that having either a substance use problem or mental health problem increased the odds that the person affected had, or would eventually have, the other problem at some point in life. Having been diagnosed with generalized anxiety disorder, bipolar disorder, or major depressive disorder, for example, put an individual three times more at risk for a substance problem when compared to the general population. Having drug problems made the person 4 to 5 times more likely than average to have a mental health disorder at some time during the life course. These findings show that addictions and mental health problems often go together.  So what are the ramifications of experiencing both types of problems concurrently?

When a person suffers from mental health problems and substance use problems the condition is named concurrent disorder. The condition combining addictions and mental disorder has also been coined dual diagnosis. (Although across jurisdictions, ‘dual diagnosis’ is currently a specialized term reserved for persons with mental illness and co-occurring developmental disability; see the Canadian Mental Health Association for definitions). Despite the label, one need not be formally diagnosed as having a psychiatric disorder for a concurrent disorder to occur; the only stipulation is that problems experienced at that given time – in both substance use and mental health – must be shown to impact a person by causing distress and/or by interfering with aspects of life, i.e., school, work, or home life.

How would you screen for a concurrent disorder? Try to imagine a student coming to your office for help. She is more likely to report mental health problems than substance abuse, particularly if she is exposed to illegal drugs or is under the legal age for using alcohol, tobacco, and cannabis. As described by the Centre for Addiction and Mental Health in Ontario (CAMH), an addiction is manifested by what is called the four Cs: (i) presence of cravings; (ii) loss of control in amount of substance used and its frequency; (iii) compulsion to use; and, (iv) ignoring the consequences. Additional clues suggesting the presence of a concurrent disorder include family tension, irritability and aggression, personality change, abandoning old friends, and getting into trouble with the law and authority figures. According to CAMH, one easy way to screen for a possible concurrent disorder is to ask these simple questions: (1) Did a psychologist or physician diagnose you with a mental disorder? (2) Have you tried to hurt yourself or ever have thoughts of self-harm? (3) Were you experiencing problems related to the use of alcohol or other drugs? (4) Has anyone close to you voiced concerns about your drinking or drug use? Teens and adults who have answered yes to screener questions of this type are at risk of a concurrent disorder.

If you are querying your students in a sensitive, caring, and nonjudgmental way, you might have discovered by now that they are more inclined to openly discuss ways in which their problems are connected and compounded. For instance, certain substances ingested at high dosages, i.e., cocaine, can bring about psychotic symptoms such as hallucinations and paranoia, and these effects can be terrifying to a young, unsuspecting adolescent. Many young people admit to experimenting with drugs and smoking but then develop no further issues. Others admit that they have felt pressured by peers to (over) use, and still others have developed a full blown dependency and abuse of drugs or alcohol that results in poor academic performance, impaired job performance, and ruptured interpersonal relationships among other concerns. These issues can pave the way for depression, anxiety, and adjustment (and other) problems. Of course, it is not always obvious as to which problem came first – the addiction or the mental health issue. Students who feel overwhelmed by schoolwork and grades, who have performance and social fears, and who become depressed following the loss of romantic relationships all have the potential to be distracted from their responsibilities, to lack focus and stamina, and to feel worthless or guilty for not having completed academic assignments and related goals.  In these cases, students might turn to substances as a way of coping with significant distress and dysfunctioning.

How might you support someone who needs help? The co-morbidity of medical, social and emotional problems in concurrent disorders is taxing on individuals because treatment of addictions and mental health issues must be integrated, and treatment usually takes a lengthy period of time. Clients are advised before formal treatment begins that the tendency to self-medicate is high for those who have been diagnosed with a mental disorder and who have been reluctant to seek therapy or psychotropic medication of more severe symptoms. Students would benefit by learning about the concept of self-medicating and the importance of seeking formal treatment approaches.

Students would also benefit from your wisdom, your attitude and your direction regarding next steps. Ask yourself whether you possess an understanding of concurrent disorders and how the underlying problems co-occur. With resources on hand, do you feel confident sharing referrals centered around private psychological services, community mental health facilities, addictions counseling, and medical and social services? If some services are not available in your local community, in what capacity, if any, do you personally feel comfortable working with young people who present with concurrent disorders?

According to CAMH, stigma surrounding mental health can be eliminated once citizens take a close look at their own attitudes and values. It is vital to understand the relation between substance use and associated illegal activities without being quick to judge. It is crucial to view substance use problems as real issues that deserve attention rather than to see them as stemming from intentional actions. By having already committed yourselves to youth in education and positive development, you probably agree that these issues are important enough to tackle.  In this sense, you truly are in a good position to provide genuine support and guidance. 

Author Bio: Sybil Geldart is an associate professor of psychology at Wilfrid Laurier University (Ontario), with research interests broadly based in developmental psychology, clinical psychology and (occupational) health. She typically teaches courses in psychopathology, clinical psychology, and exceptionalities during childhood and adolescence. Sybil is also a registered psychologist, and has a part-time clinical practice in the city of Brantford where she provides assessment and counselling to children, youth, and adults.