Not long ago, I noticed that C-SPAN was going to be featuring testimony before Congress on mental health issues and legislation. I thought I’d see what was up. What I heard was a lot of questions about the opioid crisis and what the nation’s response to that ought to be. I tuned out and turned it off. I had been hoping to hear about issues such as insurance parity, access to treatment, assisted outpatient treatment, and more. Instead, what I got was a focus on substance use and abuse.
I also recently saw a map that indicated which states had reimbursement programs for Substance Use Disorders (SUD) and Mental Health initiatives. By far, most of the programs were for SUD. States that covered mental health conditions were in the minority, and most of them provided coverage for both SUD and mental illnesses.
I’m not denying that substance use and abuse are problems in the U.S or that legislative attention needs to be paid to them. I know the opioid crisis is tragically affecting individuals and communities across the country. Nonetheless, I wish as much attention was paid to mental health issues. They affect individuals and communities, too.
I was a little short-sighted as well as impatient, however. The two topics are not mutually exclusive. Mental illness and drug use are often comorbidities (also called co-occurring disorders or dual diagnoses). Still, there are in many places rehab facilities for people who abuse drugs and alcohol, and separate facilities for people with mental illness.
The two conditions share many characteristics. Both can be attributed to brain chemistry. Very Well Mind notes, “[t]he activation of the brain’s reward system is central to problems arising from drug use. The rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.” The effects of brain chemistry on mental illnesses such as depression, bipolar disorder, and schizophrenia are not well understood and are even debated. But though the mechanisms of action on the brain may be different, there is little doubt that the brain is involved in both addiction and mental illness. Medline Plus notes that there are other similarities in causation, including genetics, stress, and trauma.
Various psychiatric disorders are associated with substance use, including psychotic disorder, mood disorders, OCD, sleep disorders, sexual dysfunction, and neurocognitive disorders. Despite this, PubMed has said, “In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.” One thorough, well-researched article with many sources listed is available from MentalHelp.net.
The latest version of the DSM recognizes the overlapping of substance abuse and mental illness, with substance-related disorders added to the DSM 5. Addiction Policy Forum reports: “The DSM-5 has eleven criteria, or symptoms, for substance use disorders based on decades of research. The DSM-5 has helped change how we think about addictions by not overly focusing on withdrawal.”
The National Alliance on Mental Illness (NAMI) says, “The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance use disorder. The idea that ‘I cannot treat your depression because you are also drinking’ is outdated — current thinking requires both issues be addressed.” They add that the treatment should consist of six elements: inpatient detoxification and inpatient rehabilitation; psychotherapy – especially Cognitive Behavioral Therapy (CBT); medications – including those that assist in detoxification; supportive housing such as group homes; self-help; and support groups, whether faith-based or not.
Of course, the idea that substance use and abuse are diseases has not caught on with many members of the general public. They consider them to be personal failings or the result of having no self-control or hanging around with disreputable friends. Perhaps that is one reason public officials do not listen to those who promote changes in legislation to improve both substance abuse and mental health care. The intersection of addiction and mental health challenges is even more foreign. Advocates who contact their legislators are likely to be brushed off with a “Thank you for contacting my office” letter. Politicians are also disinclined to listen to medical advisors on the subject, especially now that their attention is focused on COVID-19 policy.
Perhaps those who advocate for more enlightened responses to substance use and abuse issues, mental health treatment, and dual diagnoses should start a little lower. Educating legislators is fine, but change is not likely to result until their constituents demand it. For one thing, advocates for reform could attend local city or county meetings in order to counter the pervasive NIMBY (Not In My Back Yard) response to treatment facilities. They could also educate their family members and friends about the realities of drug use, mental illness, and the intersection between them. When more people understand these ideas, they may be more likely to support legislative approaches that encompass them.
Grassroots efforts such as Mothers Against Drunk Drivers (MADD) have worked in the past to contribute to societal change and legislation regarding that problem. It may take a similar effort to achieve change in how addiction and mental illness are understood and treated.
I still think the Congressperson wasn’t talking about dual diagnoses, though.