Substance Abuse: A Mental Health Issue

In recent years, the general public has become more open to discussions about mental illness and sympathetic to individuals living with psychiatric conditions. The same cannot be said about addiction, which is often viewed as a moral failing resulting from a lack of will power.

Not only is dependency on drugs and/or alcohol understood by the medical community as a treatable, chronic disease, but it frequently co-occurs with one or more other mental illnesses such as depression, anxiety or schizophrenia. Recent advancements in the understanding of addiction have led to improved therapeutic treatments. But stigma, whether imposed by others or self-perceived, is keeping many substance users from trying new therapies, leading to the strong likelihood of a further decline in their mental health.

By the Numbers¹

• About 17.5 million Americans over the age of 18 (or 8 percent of the adult population) had a serious mental health disorder in the past year. Of these, about 4 million people also struggled with a co-occurring drug or alcohol dependency.
• 210,000, individuals aged 12 or older, or 7% of this age group, were dependent on or abused alcohol during 2012-2013 in Connecticut.
• 81,000 individuals aged 12 or older, or 2.7% of this age group, were dependent on or abused illicit drugs during 2012-2013 in Connecticut.
• 33,267 individuals in Connecticut were enrolled in substance abuse treatment according to a single day count in 2013, an increase from 24,831 in 2009.
• 6% of individuals with alcohol dependence or abuse between 2009-2013 received treatment for their alcohol use.
• 20.5% of individuals with illicit drug dependence or abuse between 2009-2013 received treatment for their use.

More Connecticut data

Addiction as a Mental Health Disorder

The terms substance use, dependence, abuse and addiction each have there own distinct definitions in the medical community, and the understanding of what constitutes a mental disorder has changed over time. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the standard for the mental health field, now applies the term substance use disorders for each specific substance and uses a range of criteria to define the severity of the problem.

The bottom line is that alcohol or drug use becomes a mental health disorder when done compulsively over time and harms relationships with family, friends or coworkers.

"It's a brain disease, a compulsive and uncontrollable craving that over time has devastating consequences. And it's progressive," said Tony Corniello, Vice President of Clinical Services for BHcare, a community-based behavioral health services provider in the Valley and Shoreline regions.

Attitudes in the general public and among substance users themselves, however, have not caught up to the medical profession. A 2014 survey² by the Johns Hopkins Bloomberg School of Public Health found respondents were far more sympathetic to people diagnosed with mental illness than to individuals with drug addictions.

In one example, nearly half said that people with a drug addiction should not receive the same health insurance benefits as the general public, whereas only one-fifth responded the same about people with mental illness. Other studies³ have shown that both discrimination and self-perceived stigma contribute to the declining mental health of substance users and are barriers to them accessing treatment.

A Shift in Clinical Perspective

In his 20 years working in the mental health field, Corniello says treatments have turned away from methods that perpetuate shame and stigma.

"When you say, 'You need to stop drinking,' that doesn't work," Corniello said, adding that counselors will instead ask clients why they are in treatment and help them identify the consequences, both good and bad of their substance use.

"You have to acknowledge that it is not all bad. They are getting something positive out of their use. However, over time if you look at the consequences, they significantly outweigh the positive effects. Instead of going home at night, you might go to jail."

Corniello said treatment programs are also more likely than in the past to help substance users find productive activities or even a job.

The medical field has also shifted away from thinking about substance abuse and mental illness as distinct issues when they occur with the same patient. In many cases, substance abuse is understood to result from a patient's attempt to self medicate in order to find relief from other disorders.

"We don't get so focused on what came first. We treat them together," Corniello said. "Providers used to take an abstinence approach and say they need to be clean before we treat them. Well, schizophrenics are not necessarily going to stay clean if they are still hearing voices."

At Bridges in Milford, upwards of 75% of patients receiving mental health treatment have co-occurring psychological and substance use disorders, known as dual diagnosis, according to President and CEO Barbara DiMauro.

Like BHcare, Bridges' clinicians attempt to meet the patient where he or she is and create an individualized therapy plan. This often involves a medically approved drug that reduces cravings in combination with cognitive behavioral therapy, which helps people control and ultimately change their negative and destructive patterns of thinking and feeling.

"What we know now about addictions as compared to 20 or 30 years ago is phenomenal," DiMauro said. "The prevailing thinking had been that it was a character issue. Now we have pharmacological interventions that help change the brain chemistry so you don't have that compulsive feeling."

While cognitive behavioral therapy has proven successful in helping people break their patterns of substance abuse, it is out of reach for many. There are not enough trained therapists in many parts of the country to meet the need, and turnover in many clinics is high. To overcome these barriers, Yale School of Medicine researchers have tested a computer-based cognitive behavioral therapy program and found it effective with patients on a methadone maintenance program.

In practice, not all mental health professionals agree with diagnosing and treating an individual's mental illness before first addressing a co-occurring substance use problem. People who walk into the Connecticut Mental Health Center in New Haven seeking treatment for a psychiatric disorder are routinely referred to its substance abuse unit across town if they are intoxicated, according to Donna LaPaglia, Director of the Center's Substance Abuse Treatment Unit.

"It's still separated," LePaglia said.

Access

Community mental health centers like BHcare are designated to provide services to anyone who walks in the door, regardless of ability to pay. Prior to their existence, mental health services were primarily delivered in large institutional settings. The movement to deinstitutionalize that began in the late 1960s held the promise of saving money while also providing better outcomes because patients could remain in the familiar environments of their own communities.

But the funding to the community-based centers has not kept pace with the need for services.

"We've been underfunded for over 20 years and have seen just a half percent increase in the last 7 years," said Emily Granelli, BHcare Director of Communications & Legislative Affairs. We've become as efficient as possible, but it's difficult."

The result has been waitlists of up to 10 days for people seeking treatment and an increased use of group therapy as opposed to individual sessions.

"What might not be an emergency today, might become and emergency in 10 days," said Granelli. "And our population, unfortunately, is growing."

What The Community Foundation is Doing

Recent grants to organizations providing behavioral health and substance abuse treatment services in the region include:

• The Connection, for the renovation of bedrooms, bathrooms, and kitchens in the 13-bedroom Park Street Residence Program, which provides housing and mental health services for individuals with a dual diagnosis of mental illness and addiction.
• Fellowship Place, for general operating support to bridge a gap between government funding and operational costs. Fellowship Place New Haven supports the severely mentally ill in New Haven with year-round services including homeless engagement, supported education, employment services, supported Housing, social Rehabilitation and an alternative-to-incarceration program. One third of Fellowship Place clients have a co-occurring substance abuse problem.
• Bridges- A Community Support System, for general operating expenses to reduce the wait list and to support a range of mental health, addiction and recovery programs. Bridges serves about 1,300 adults and children at a given time.
• BHcare, for general operating expenses to support comprehensive behavioral health services for more than 10,000 clients in the Valley and Shoreline regions. Funding has also been provided by The Community Foundation's philanthropic partner, the Valley Community Foundation.
• APT Foundation, to support a childcare program for parents in substance abuse treatment.

Works Cited

1. Substance Abuse and Mental Health Services Administration. Behavioral health Barometer: Connecticut, 2014. HHS Publication No. SMA-15-4895CT. Rockville, MD: Substance Abuse and Mental Health Services Administration 2015.

2. Barry, Colleen L. et al. Stigma, Discrimination, Treatment Effectiveness, and Policy: Public Views About Drug Addiction and Mental Illness. Psychiatric Services, Volume 65 Issue 10, October 2014, pp. 1269-1272.

3. Ahern, Jennifer et al. Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence Volume 88, Issues 2–3, 11 May 2007, Pages 188–196.