Historically, mental illness and addiction have typically been seen as separate, unrelated issues.
But around half of patients with addiction issues also suffer from co-occurring mental illness, according to the Substance Abuse and Mental Health Services Administration, the arm of the U.S. Department of Health and Human Services concerned specifically with the two eponymous conditions.
But traditional addiction treatment programs address only substance abuse. This approach can result in frequent relapses that put addiction patients back in treatment repeatedly, catching them in what's known as the "revolving door."
The co-occurrence of mental health and addiction is one of the hottest topics in contemporary behavioral health, yet according to a 2013 report published in the annual medical publication Journal of Dual Diagnosis, only around 18% of addiction treatment programs and 9% of mental health programs are dual-diagnosis-capable. In other words, a large majority of programs are not equipped with the expertise to treat both types of condition at the same time.
We spoke to Tonmoy Sharma, a trained psychiatrist specializing in addiction medicine and the CEO of Sovereign Health Group, a San Clemente-based national provider of behavioral health services that operates dual-licensed residential treatment centers for addiction, mental health and dual-diagnosis care. He sat down for a Q&A session and offered some insight on the dual-diagnosis approach — and why he believes it's the only effective way to treat addiction.
What exactly is dual-diagnosis?
In the context of addiction treatment, it's a situation in which a patient with a diagnosis of substance misuse also has a diagnosis of a mental illness.
In dual-diagnosis, does substance abuse lead to a mental health disorder or does a mental health disorder lead to substance abuse?
It works both ways. If you continuously drink alcohol, you're likely to get depressed. If you're depressed, you're also likely to drink. So it's essentially a chicken-and-egg situation, and the origins and causes of substance abuse and mental health disorders differ from person to person.
How would you characterize the medical profession's current understanding of the phenomenon of addiction and co-occurring mental issues?
I think people need to understand that addiction doesn't exist in a vacuum. So, to treat a patient effectively, a good addiction specialist must possess the expertise necessary to address both the addiction itself as well as the mental illness that's exacerbating and being exacerbated by the addiction. Much of the time, treating the addiction alone just isn't enough.
Here's an example: You suffer from depression, and you've started drinking. So you enter a traditional treatment program, where you abstain from drinking. When you complete the program, you've stopped drinking — but you're still depressed. So you end up drinking again because it helped you cope in the past.
As soon as you take that first drink, according to the treatment facility, you have failed. Wrong — the treatment facility has failed because it did not address your core problem: depression.
So is mental health expertise therefore crucial to a facility being able to effectively treat addiction?
Yes. An unfortunate distinction has developed in the treatment community: the idea that patients can be successfully treated as if their substance abuse were a standalone issue. On the contrary, any proper addiction treatment facility should really be licensed to treat mental health, and it ought to be staffed with professionals who have adequate expertise in psychology and psychiatry as well as addiction treatment.
To be dually licensed to treat both mental health and substance abuse is vital. At Sovereign Health, we are dually licensed, and our clinicians are superbly trained because we firmly believe that it is essential to treat the mental health problems underlying addiction.
Which psychological conditions most often influence, and co-occur with, addiction problems?
There are many. ADHD [attention deficit hyperactivity disorder] commonly shows up in tandem with addiction. So do bipolar disorder, depression, post-traumatic stress disorder and anxiety.
We often find that once we start treating somebody's addiction, that's when the mental health problems surface. In fact, a large number of our referrals come from other treatment centers that have treated the addiction in a patient, for instance, but find themselves ill-equipped to handle that patient's uncontrolled bipolar disorder.
If a patient has a substance use problem and an underlying mental health disorder and only one of those conditions is treated, what can be the result?
The result is partial treatment — and the possibility or the high likelihood of relapse. That's a big reason we see such poor outcomes for patients in the field of addiction treatment. That's why we see so many revolving-door patients. These people haven't been wholly treated. It's like [only] treating a chest infection in an HIV patient. You've addressed the symptoms, but the core and enduring problem remains.
Many patients are unaware of their co-occurring conditions, so how does Sovereign go about detecting and defining these?
We do a detailed diagnostic assessment. Many facilities get a brief history from patients before tossing them into group therapy and talking to them about abstinence. Not at Sovereign.
We perform a full assessment of brain function — the cognitive assessment — so we can find out what is truly wrong with the patient. Obviously, they're with us because they have an addiction problem. But do they also have a mental illness? We have them see a trained psychiatrist. If there's a mental health issue at play, we treat it with the respect it deserves.
What sorts of level and standards of care should family members be seeking when looking into dual-diagnosis treatment for a loved one?
They should be looking for centers that are dually licensed — and not only the minimal state medical board licensing, but also accreditation from recognized federal accreditation bodies like [national nonprofit medical evaluators] the Joint Commission.
Family members should also take a look at the quality and caliber of the staff, as well as their educational background. Are they at master's [degree] level and above, or are they just counselors? You need to know who is going to be treating your loved one. Are they truly qualified, or are they basically life coaches and caretakers? This is not 'destination rehab.'
Can you describe the emerging model of cutting-edge treatment programs based on dual-diagnosis being offered by facilities such as Sovereign?
It's fairly straightforward: Our clinicians perform the medical assessment when the patient arrives, followed by a thorough evaluation of their symptoms and cognitive function. Then we develop an individualized treatment plan for that patient that's based on the results of our assessments. We follow a medical, scientific model.
It's important to quantify symptoms and problems in brain function when somebody comes in. We need more of this type of measurement-based care in addiction treatment. At Sovereign, our assessment is so thorough that our patients even see a physician.
So Sovereign embraces an evidence-based, medical approach to treating addiction rather than the nonscientific "12-step" approach that still dominates the field?
That is correct. People in treatment at Sovereign are free, and we encourage them to attend 12-step meetings in the evening. Twelve-step is a great fellowship, but it isn't treatment. Support is a good thing, but it also doesn't equal treatment. That's what we're emphasizing.
Does Sovereign Health offer therapeutic activities for patients?
Yes. We're very inclusive in what we do. We offer a variety of therapeutic and holistic activities such as equine therapy, mindfulness and yoga. There's evidence that mindfulness [focusing on a calm awareness of the present moment] alters brainwaves.
What are the latest technological advances in the mental health field that people will see at Sovereign?
They'll see that we're using computerized testing to assess cognitive function. We're incorporating cognitive remediation [a therapy technique based on drills and practice] in order to improve brain function. We're using TMS — [noninvasive] transcranial magnetic stimulation — for people who have refractory depression and aren't responding to treatment.
We're also exploring neurofeedback, where we're looking at quantitative EEGs [results from noninvasive tests of electrical activity in the brain], studying brainwaves, and then teaching patients how they might self-regulate and control these brainwaves.
Sovereign offers residential treatment. Why is the residential element significant?
Our structured residential setting removes patients from the distractions and stresses they might have at home. That's such an important part of recovery, whether it's from a mental illness or whether it's from addiction.
Our residential treatment is immersive. We're treating patients from 30 to 90 days: maybe 15 to 30 days in residential treatment, then people drop down to partial hospitalization, and then intensive outpatient treatment.
But your treatments are affordable for average Americans, correct? And they're usually covered by health insurance?
Yes. Ninety-nine percent of our patients are here on their insurance.
Finally, what do you see as imminent advances and trends in the field of dual diagnosis and treatment for addiction patients?
We need to be carrying out more measurement-based care. We need to have standards of care that people can rely on — that the consumer can rely on. And I think that, as a community, we need to come together to make sure that those standards of care are available in residential treatment.