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This paper critically evaluates the literature on the co-occurrence of substance-use disorders (SUDs) with other psychiatric conditions. Our review considers the variety of different associations between the two, and suggests the implications of the literature for the design of treatment services that address both types of disorders. Methods: A narrative review of research and theory was conducted, covering epidemiology of co-occurring psychiatric disorders worldwide, mechanisms underlying co-occurrence, and treatment models. Results: Epidemiological research has documented a high prevalence of co-occurring disorders in both clinical samples and the general population, although the literature is based primarily on studies in high-income countries and some of the overlap might be due to the co-occurrence of milder forms of both types of disorders. Consistent with what has been reported in other reviews, we conclude that clients with co-occurring disorders tend to have a more severe course of illness, more severe health and social consequences, more difficulties in treatment, and worse treatment outcomes than clients with a single disorder; we address the implications of these findings for the design of treatment services. Conclusions: Much of the evidence shows that separately, treatments for both SUD and other psychiatric disorders are effective in reducing substance use and in improving behavioral, familial, and psychosocial outcomes. The evidence further suggests that these outcomes might be improved when treatment modalities are offered in combination within an integrated treatment plan that simultaneously addresses substance abuse and psychiatric problems. It is concluded that there is potentially more to be gained from taking a public health perspective and working on efforts to implement existing evidence-based practices at the systems level, than from the current tendency to look for ever more powerful individual-level interventions at the clinical level.
Many planners and administrators now look to “collaboration” or “integration” as a solution, or at least a partial solution, to challenges related to access and delivery of substance use and mental health services and health services in general. Among the major constraints in identifying best practices in this area and recommending optimal evaluation strategies are the plethora of terms and concepts used in the literature to describe collaboration or integration as well as the many alternative approaches and outcome expectations. It is helpful, therefore, to follow concrete steps to plan the evaluation, including the engagement of multiple stakeholders in the planning process and subsequent execution of the evaluation. The concrete evaluation strategies employed can follow a traditional, often linear model, of impact and are often categorized under the common typologies of process, outcome or economic evaluations. Each approach examines different domains of interest and can be at the individual/service level or at the level of the overall treatment system. Other less traditional evaluation models and methods based on systems theory, complex adaptive systems and developmental evaluation have much to offer the evaluation of interventions aimed at improving the collaboration and integration of substance use services with other health and social services and sectors. Realist evaluation is a particularly helpful approach that integrates many of the traditional approaches with these other models and methods.
Mental health problems in Finland have been the responsibility of the health care, and substance abuse problems have been handled within social care. In 2009, a national reform aiming at integrating mental health and substance abuse treatment systems (SATS) was launched. The critics of integration were concerned that it implies a medicalization and a narrowing of the social care goals.
This article analyses to what extent integration of mental health and SATS affect the capability to treat co-occurring substance abuse and mental health problems. A secondary aim is to assess the utility of the DDCAT (Dual Diagnosis Capability in Addiction Treatment) instrument in a Finnish context.
The study is based on group interviews, using DDCAT, in six Finnish municipalities, three with integrated and three with separate mental health care and SATS. The assessment pertains to the main outpatient unit in the city.
The dual diagnosis treatment capability did not depend on the system-level integration. Two municipalities where SATS was administratively separate from mental health care were able to achieve high dual diagnosis capability ratings while in one municipality with system level integration this capability was not very high. The DDCAT instrument puts an emphasis on medical staff and competence.
Strong, separate local SATS may adapt to the integration demands or needs by strengthening their psychiatric competence. This solution can result in treatment that is equally competent in treating mental health and substance abuse problems as integrated systems. The DDCAT instrument can be useful in a Finnish context to measure medical competence to handle dual diagnoses, irrespective of system solutions. For a balanced measurement, the instrument should be complemented with a section mapping competence to handle co-occurring social problems.
For a Swedish national sample of 12,833 individuals assessed for a substance use disorder (SUD) (2002-2008) in the Swedish welfare system, client self-report and clinical staff Addiction Severity Index (ASI) assessment data were used to assess mental health problem severity and needs.
Analysis of client self-report data using regression methods identified demographic characteristics associated with reporting significant mental health problems. Clinical staff assessment data from the ASI Interviewer Severity Rating (ISR) score were used to develop a K-means cluster analysis with three client cluster profiles: Narcotics (n=4795); Alcohol (n=4380); and Alcohol and Psychiatric Problems (n=3658). Chi-square and one-way ANOVA analyses identified self-reported mental health problems for these clusters.
44% of clients had a history of using outpatient mental health treatment, 45% reported current mental health symptoms, and 19% reported significant mental health problems. Women were 1.6 times more likely to report significant mental health problems than men. Staff assessed that 74.8% of clients had current mental health problems and that 13.9% had significant mental health problems. Client and staff results were congruent in identifying that clients in the Alcohol profile were less likely (5%) to report having significant mental health problems compared to the other two profiles (30% each).
About 19% of clients with SUDs reported significant mental health problems, need integrated addiction and mental health treatment, and these clients are clustered in two population groups. An additional 25% of the addiction treatment population report current mental health symptoms and have at some point used mental health treatment. This national level assessment of the extent and severity of co-occurring disorders can inform decisions made regarding policy shifts towards an integrated system and the needs of clients with co-occurring disorders.
Far-reaching changes in the Swedish substance abuse treatment system (SAT) were proposed by a state-commissioned inquiry in 2011. The proposal implied a break with the social tradition of SAT. It was suggested that the treatment responsibility should be transferred from the municipal social services to the regional-level health care system; and that compulsory treatment in its present form (assessed by/paid for by social services, run by the state) should be abolished and become incorporated into coercive psychiatric care provided by health care. A lively debate arose, and the vast majority of stakeholders sought to articulate their arguments.
The study analysed the development of Swedish SAT by examining the policy process from reform proposal to government bill in 2013.
Content analysis was used to analyse written comments on the proposal submitted to the Ministry of Health and Social Affairs by close to 200 stakeholders. The goal was to empirically chart and examine the arguments for and against as well as advocates and opponents of the reform. With the government bill at hand, we retrospectively sorted out the winning arguments in the now highly contested SAT field and which actors were able to influence the process.
The article discloses that the mixed response and rather critical voices in most groups, including social/medical professions and government bureaucracy, helped block the responsibility shifts, and that reformations of subsystems like SAT are difficult to carry out as freestanding projects within larger systems of social and health care.


