Principles of care for young adults with co-occurring psychiatric and substance use disorders

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This entry is our analysis of a review or synthesis of research findings considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the review. Below is a commentary from Drug and Alcohol Findings.

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Principles of care for young adults with co-occurring psychiatric and substance use disorders.

Spencer A.E., Valentine S.E., Sikov J. et al.
Pediatrics: 2021, 147, S229.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Spencer at andrea.spencer@bmc.org.

[Consultation draft subject to amendment and correction.] A group of paediatric addiction medicine experts in the US review the evidence base and agree on practice considerations for the care and treatment of young adults with co-occurring mental health and substance use problems. The principles of care identified in this document highlight the need for collaborative care, the use of both trauma-specific and trauma-informed interventions, and continual reassessment of symptoms and goals throughout treatment.

Summary Over 50% of people aged between 18 and 25 years with substance use abstract disorders have at least one co-occurring mental illness, and the presence of co-occurring disorders worsens SUD outcomes. Treatment of both co-occurring psychiatric disorders and SUDs in young adults is imperative for optimal treatment, yet many barriers exist to achieving this goal. The aim of the featured paper was to communicate a series of evidence-informed principles of care pertaining to family members of young adults (defined as people aged 18–25) with substance use disorders, agreed by a national group of paediatric addiction medicine experts in the United States. Most of the evidence presented in the following article is based on information gleaned from adolescents and extrapolated to the young adult population.

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Key points
From summary and commentary

Principles of care for young adults with co-occurring mental health and substance use problems:

Principle 1: Young adults should receive integrated mental health and addiction care across treatment settings

Principle 2: Care should be responsive to the needs of young adults exposed to trauma and other ACEs

Principle 3: Treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders

Principle 1: Young adults should receive integrated mental health and addiction care across treatment settings

Evidence. The Quadrant Model (see image) was proposed in 2002 as a framework for integrating care for patients whose symptom severity varies along the two axes of substance use disorders and psychiatric disorders (15). Initial validity and feasibility studies in adults indicate that the model accurately characterizes patients and their needs.16,17 The greatest evidence for integrated care exists for adults with severe mental illness (SMI; defined as chronic, long-term psychiatric disorders18) and substance use disorders, who fall into quadrants II (SMI plus mild substance use disorder) and IV (SMI plus severe substance use disorder) and receive services largely through mental health agencies. In their 2001 review, Drake et al18 described the evidence supporting dual diagnosis services (in which a single team, usually at a mental health agency, provides care for both disorders) for patients with substance use disorder and SMI. They identified several critical components of these programs (Table 1) supported by results from 8 studies that demonstrated improved outcomes for patients receiving dual diagnosis treatment.18 They also suggested that mental health agencies caring for patients with SMI should designate a clinical leader to ensure availability of dual diagnosis services for patients within the agency. Otherwise, there may be cases in which acute psychiatric treatment may be needed first because of safety concerns, such as acute suicidality or psychosis.19 For patients in quadrant I (mild substance use disorder and mild psychiatric disorder), in which there is likely to be a disproportionate number of adolescents and young adults, an increasing body of literature supports the integration of care for both disorders in the primary care setting, particularly as part of the patient-centered medical home (PCMH).20,21 In the PCMH, the primary care practice coordinates care for patients with chronic conditions across multiple providers and episodes of care.20,21 Evidence reveals that patients are more likely to access psychiatric care when integrated mental health providers conduct evidence-based interventions within primary care or collaborate with off-site mental health providers.21 The collaborative care model has the most evidence for integrating either mental health or substance use disorder treatment within primary care.22 Collaborative care involves a multidisciplinary team of providers (typically a masters-level care manager, specialty mental health provider, and primary care provider) working together to systematically identify and evaluate patients; provide evidence-based treatment using stepped care algorithms; and use patient reported measures to monitor progress and guide next steps.23 Collaborative care improves engagement in care and outcomes for adolescents and young adults with psychiatric disorders,21 and a small body of literature has begun to support its use for individuals with substance use disorders.21,24,25 Evidence also supports screening young adults and adolescents in primary care for substance use with validated tools such as the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble),26,27 and for psychiatric symptoms with validated tools such as the 9-item Patient Health Questionnaire.28 The US Preventive Services Task Force recommends screening for substance use in adults when appropriate follow-up services could feasibly be provided (grade B recommendation) but found insufficient evidence to make a recommendation on screening adolescents.29,30 For young adults in quadrant III of the quadrant model, there is emerging support for specific strategies, most notably the Adolescent Community Reinforcement Approach (A-CRA).31 Numerous randomized trials among adolescents and young adults have demonstrated the efficacy of the A-CRA, adapted from its adult version, to reduce both substance use disorder and psychiatric symptoms in youth with co-occurring conditions.31 A-CRA is a treatment based on positive reinforcement and operant conditioning principles for reducing substance use. The manualized intervention incorporates treatment strategies for individuals with co-occurring conditions, such as delivering evidence-based therapies for co-occurring conditions and facilitating adherence to psychotropic medication. Some psychopharmacological studies have supported concurrent medication management for co-occurring disorders in the outpatient setting, although the effect of such management varies by condition. For example, among 170 men and women aged 21 to 75 years with co-occurring depression and alcohol dependence, sertraline plus naltrexone led to significantly higher abstinence rates and longer time to relapse.32 However, this is not the case for all conditions and presentations, and some may necessitate sequential treatment. For example, it may be necessary to delay the prescription of controlled medications for a psychiatric condition until an substance use disorder is stabilized (as in the treatment of attention-deficit/hyperactivity disorder among young adults, who are at risk for misuse and diversion of stimulant medication).33,34 Despite the evidence for integrated treatment of co-occurring disorders, mental health and addiction care is still rarely integrated within one system or provider team,20 which can lead to one disorder going undetected and untreated,35 or to conflicting treatment recommendations (eg, peer-support groups such as 12-step programs may discourage patients from taking psychotropic medications,36 and psychiatric treatment programs may require a commitment to abstinence37). When this happens, treatment in either scenario may be rendered less effective. More evidence is needed for specific interventions and systems-level strategies to provide optimally integrated care for adolescent and young adult patients.

Practice considerations. Care coordinated through their primary care physician may an important point of treatment entry for young adults with co-occurring disorders. However, many young adults may stop paediatric care without establishing adult primary care and therefore have “no medical home” to speak of. This age group is less likely to have a primary care provider, or receive preventive medical care than any other age group. In contrast, some young adults and their families who are engaged with paediatric care may resist transitioning to adult services, in part from concern that adult providers may not be as responsive to developmental needs. Therefore, a specific addiction or mental health programme may need to step in to coordinate care when a patient has ‘no medical home’ or during acute episodes requiring higher level care.

Principle 2: Care should be responsive to the needs of young adults exposed to trauma and other ACEs

Evidence. Trauma Exposure and ACEs Trauma and ACEs, including physical or sexual abuse, neglect, or family dysfunction, are common in the general population. However, individuals who use substances are more likely to have been exposed to trauma and other ACEs and are more likely to develop subsequent physical and psychological consequences.44,45 An estimated 75% of adults in substance use treatment report interpersonal abuse and trauma histories.46 Whereas 13% of adults in the general population report exposure to 4 or more ACEs,47,48 84% of those with substance use disorder report such exposure.49 Among the adult population, a dose-response relationship has been documented between number of ACEs and a range of negative health outcomes, including increased risk for substance use disorders, psychiatric disorders including depression, and suicide attempts.50,51 One study found that adults with 4 ACEs (versus none) were twice as likely to report heavy drinking and 3 times as likely to report alcohol problems in adulthood.52 ACEs and childhood trauma are associated with worse outcomes in substance use treatment, including higher severity of and shorter time to relapse.5355 Assessment of Trauma History, ACEs, and Related Mental Health Problems PTSD is one potential mental health consequence of traumatic events. Traumatic events are experiences meeting Criterion A for a diagnosis of PTSD (ie, exposure to life threat, serious injury, or sexual violence).46,56 Standardized tools to assess trauma exposure and related distress have been validated in populations with co-occurring substance use, but evidence suggests that they are seldom implemented in substance use disorder treatment settings.57 Authors of 2 high-quality systematic reviews outline the best assessment tools for PTSD among adults and adolescents,58,59 including the PTSD Checklist for DSM-560 and the Life Events Checklist.61 The Primary Care PTSD Screen49 can be used as a brief screener for PTSD, followed by a diagnostic assessment.58,60 Standardized assessments also exist for ACEs, including the Centers for Disease Control and PreventionKaiser Permanente Adverse Childhood Experiences Questionnaire,62 Behavioral Risk Factor Surveillance System (BRFSS) ACE63 items, and the Center for Youth Wellness Adverse Childhood Experience Questionnaire (CYW ACE-Q).64,65 Trauma-Informed Services We are not aware of any randomized studies examining the efficacy of trauma-informed care; thus, our recommendation for trauma-informed services comes from observational data. The absence of data supporting trauma-informed services is largely due a lack of standardization of services or interventions, which leads to an inability to assess causal effects of specified approaches on clinical outcomes66 or to draw comparisons across studies. In practice, trauma-informed care typically involves staff trainings to promote awareness about biases and practice considerations for vulnerable populations. Findings from a systematic review suggest that these trainings improve provider knowledge across a variety of child-serving settings,66 but none has examined patient outcomes. Thus, there is a need to standardize trauma-informed services and test their effect on provider behaviours and patient outcomes.

Trauma-Specific Services Several efficacy and effectiveness studies have found that treatment of PTSD can reduce substance use but that treating substance use has minimal impact on PTSD symptoms.67 For example, a treatment study in women with dual PTSD-substance use disorder diagnoses found a temporal association between PTSD symptom reduction and number of days of substance use.67 Thus, PTSD-specific treatments may be warranted within substance use programs, and these may include established evidence-based PTSD treatments or dual PTSD-substance use disorder treatments. There are several evidence-based therapies for PTSD for adolescents and adults, based largely on cognitive behavioural therapy models, and there are several systematic reviews and meta-analyses on psychotherapies for PTSD.68 Common components across evidence-based therapies for PTSD include psychoeducation, relaxation training, exposure, and cognitive restructuring. PTSD treatments with the strongest evidence include cognitive processing therapy, prolonged exposure therapy, and eye movement desensitization and reprocessing. Cognitive processing therapy and prolonged exposure therapy have demonstrated effectiveness for use with adolescent and young adults with PTSD,69,70 but there is scarce evidence on their use for co-occurring PTSD and substance use disorder; only preliminary research exists in dually diagnosed adults.7174 As an example of how treatments can be tailored for youth and young adults, developmentally adapted cognitive processing therapy includes a preparation phase to enhance motivation, emotion, and behaviour management techniques for high risk behaviours, recognition of developmental tasks (ie, education about abusive partners, inclusion of social network), and a massed delivery of sessions (ie, .1 per week) to capitalize on fluctuations in motivation.75 Several integrated treatments have been developed recently to dually target substance use and PTSD symptoms,67 but only Seeking Safety has preliminary evidence for effectiveness with young adults.76 Seeking Safety is a present-focused therapy that focuses on cognitive, behavioural, and interpersonal coping skills and case management needs of clients.77 It can be delivered in individual or group format. Integrated treatment combines cognitive behavioural therapy components from evidence-based treatments for PTSD and substance use disorder (eg, relapse prevention).78 There are several widely used, Substance Abuse and Mental Health Services Administrationapproved integrated treatments considered promising practices without strong efficacy data.44,45 Programs should consult the National Trauma Consortium guidelines to stay abreast of current best practices.79 There are medications with moderate efficacy for PTSD symptoms but a limited number of studies in individuals with co-occurring disorders.80 The best evidence exists for selective serotonin reuptake inhibitors, which have been shown to reduce PTSD symptoms in adults with co-occurring alcohol use disorder and PTSD.81.

Practice considerations. Trauma survivors report distress in care settings related to feelings of a lack of trust, safety, and sense of agency. In some cases, clinical experiences (such as physical touch, a provider’s physical appearance, or loud noises) may be reminders of a traumatic event and prompt distress. Therefore, providers should aim to develop trust over time, provide care in an unhurried fashion, talk about procedures before doing them, and validate and normalise concerns. Treatment providers and systems may also establish procedures to reduce risk of additional trauma exposure in patients’ lives, especially in the context of familial or dating relationships. This could include addressing housing and financial circumstances that increase vulnerability to victimisation or providing education on healthy relationships (eg, to improve selection of partners with lower violence risk) and connection to additional community resources (eg, shelters, advocacy groups). Assessment of trauma history (initiated by the provider) is critical. Providers may be hesitant to ask about trauma because of concerns about upsetting patients or not having resources to offer after disclosure. However, requiring patients to be forthcoming about trauma history is problematic for multiple reasons:
• Studies reveal patients are often unaware of the relationship between trauma exposure and current substance use. Therefore, patients may not mention past trauma because they do not recognise its relevance.
• Survivors may be reluctant to disclose trauma because of shame and guilt, fear of judgment, or concern about resulting family discord.
• Reluctance to disclose trauma or engage in trauma-specific services may also be due to symptoms of PTSD, such as avoidance of the trauma memories and reminders.

For providers who have concerns about patients’ distress during these assessments, the literature provides some reassurance. One study found that even lengthy and sensitive trauma assessments were acceptable to most female subjects surveyed about assessments they had completed for a randomised controlled trial of treatment for post-traumatic stress disorder. Brief upset may occur for some patients, but is not counterproductive. For example, one study (84) found that those who endorsed greater upset during assessments were more likely to complete PTSD-focused treatment, suggesting it may have facilitated insight-building about the importance of treatment.

Principle 3: Treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders

Evidence. Ambivalence among young adults about changing their behaviour and engaging with treatment is to be expected. This population faces multiple unique barriers to care, including due to hesitating to disclose symptoms or accept treatment because of fear of public stigma (societal and familial negative attitudes toward addiction and mental health treatment) and self-stigma (internalized negative feelings toward oneself because of perception of public stigma). Adolescence marks the beginning of a progression of health care disengagement. Young adults from immigrant and minority groups face cultural factors that heighten stigma, disparities in health care access and quality, and discrimination, inducing cultural stress and poor trust in health care.94 Therefore, providers should use evidence-based strategies designed to increase engagement in and motivation for care, including motivational interviewing (MI), motivational enhancement therapy (MET), and shared decision-making. MI is a treatment approach based on the stages of change theory that helps patients develop intrinsic motivation to change problematic behaviors.87 Although initially developed to target substance use, MI has shown promise for use with young adults with co-occurring psychiatric and SUD.95,96 For example, researchers in one randomized controlled trial found that an integrated model of MI and cognitive behavioural therapy for young adults with comorbid schizophrenia and SUD led to both reduction in positive symptoms of schizophrenia and an increase in abstinent days over a 12-month period.95 In another randomized study, psychiatrically hospitalized adolescents with co-occurring conditions who were randomly assigned to a 2-session MI intervention versus treatment as usual had both a longer latency to first use as well as less use in 6 months postdischarge.96 MET is another evidence-based technique for the treatment of SUD. MET includes MI plus formalized feedback to the patient on their current substance use42 and moves the young person toward identifying her own goals and values in treatment, desires for change, readiness, and expectations for achieving sobriety. Preliminary evidence suggests that MET could also benefit certain populations of adolescents and young adults with co-occurring disorders.97 For example, over 2 years, researchers in one randomized controlled trial found that adolescents ages 15 to 20 years with comorbid major depressive disorder and alcohol use disorder who received an intervention combining cognitive behavioural therapy and MET had significantly greater reduction in both depressive symptoms and alcohol use disorder compared with those who did not receive the intervention.97 Shared decision-making is an approach for partnering with patients and families to select medical treatments in a patient and family-centered manner, with evidence supporting its use for multiple medical conditions.98 Shared decision-making offers a structured process for collaboratively exploring the potential consequences of treatment options, and for making choices in the context of individual values and preferences.99 Although shared decision-making is a useful concept with evidence in other areas of medicine, there are limited data on its effectiveness in SUDs and mental illness.100 One randomized controlled trial found a reduction in both substance use and psychiatric symptoms with the use of a shared decision-making intervention compared with usual protocols for deciding treatment options.75.

Practice considerations. Young adulthood typically represents a time of shifting from being dependent (ie, on parents) to being independent. As well as this being a major psychological process, it can have practical implications, for example taking the young adult from being the receiver of guidance to someone who makes decisions or collaborates in decision-making. Treatment that is responsive to this developmental milestone by placing young adults at the centre of decision-making may be important for engaging young adults with co-occurring disorders in care. At the same time, family and other loved ones can continue to play a critical role in treatment, and providers can engage families by providing information about evidence-based options. Families may need support and encouragement to give young adults space and time for weighing decisions, building trust with providers, overcoming stigma, and prioritising care. However, ultimately, young adults have the authority to decide on the role of family and other loved ones in their care.

The authors’ conclusions

Young adults with co-occurring mental health and substance use problems represent a vulnerable (yet potentially resilient), and difficult-to-engage population. Treatment systems and providers should consider putting in place the necessary steps and support provisions in place to detect, monitor, and treat co-occurring conditions. This should include: partnerships with other providers and settings to deliver collaborative care; the use of both trauma-specific and trauma-informed interventions; and continual reassessment of symptoms and goals throughout treatment, facilitated by the use of motivationally-based and shared decision-making strategies.


Findings logo commentary The featured paper is the fourth in a set of papers covering the principles of care for young adults with substance use disorders, written by a working group of paediatric addiction professionals in the US. See the full set below:

  1. Evidence-based substance use treatment of young adults with substance use disorders
  2. Engaging the family in the care of young adults with substance use disorders
  3. Support services for young adults with substance use disorders
  4. Principles of care for young adults with co-occurring psychiatric and substance use disorders
  5. Principles of harm reduction for young people who use drugs
  6. The justice system and young adults with substance use disorders

In the UK, there is no more important document for UK clinicians involved in treating problem drug use than the ‘Orange guidelines’ (last published in 2017) – based on evidence and professional consensus on how to provide treatment for most patients, in most instances. These guidelines highlight considerations for children and adolescents as well as older people, but do not specifically address the population of young adults with substance use problems.

The complexity and challenge of ‘dual diagnosis’

With the vast majority of their clients also experiencing mental health problems, deciding how to respond is a major concern for Britain’s drug and alcohol services. Should substance use services take the lead in coordinating their clients’ care, or should this be taken on by mental health services? Is either willing and able to take on both issues, or would a better option be to create new integrated services? An Effectiveness Bank hot topic considers this issue, exploring barriers to the provision of appropriate support, as well as the many opportunities and occasions to improve the lives of those affected.

Documents relevant to practitioners and service providers in the UK, each of which has been analysed in the Effectiveness Bank, include:
Guidance from Public Health England (2017): Better care for people with co-occurring mental health and substance use problems begins with commissioners and service providers adopting the principles that there is ‘no wrong door’ for accessing support, and it is ‘everyone’s job’ the other side of the door to help.
Guidance the UK’s National Institute for Health and Care Excellence (NICE) (2016): Rather than creating specialist ‘dual diagnosis’ services, health and social care (including substance use) services should adapt to patients with substance use problems and severe mental health problems, and collaborate in their care, led by the mental health service.
Guidance from NICE (2011): Substance use tends to worsen outcomes for people with psychosis partly because the substances used can exacerbate the psychosis, and partly because they can interfere with pharmacological or psychological treatment.

This draft entry is currently subject to consultation and correction by the study authors and other experts.

Last revised 01 April 2021. First uploaded 01 April 2021

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