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The purpose of this paper is to report on the success of an initiative involving the transformation of a group of small substance use treatment only or mental health treatment only provider agencies serving uninsured adults into providers of co-occurring disorder treatment.

The paper uses a case study narrative to describe the initiative and the transformation of the participant agencies from being providers of mental health or substance use treatment to providers of co-occurring disorders.

Six agencies serving uninsured adults expanded their scope of patient treatment services to include the capacity to treat adults with co-occurring disorders. This was achieved with modest support funding from a local foundation. The initiative has been ongoing for five years.

The outcome of this initiative demonstrates the financial and practical feasibility of improving and expanding treatment services to low-resourced patient populations. The participating agencies were able to improve their capacity to treat patients with substance use or mental health issues that previously they were not prepared to treat and thus increased their ability to provide integrated care.

The initiative described here shows that the treatment of concomitant substance use and mental health disorders is within the range of many small-scale treatment providers, if provided the leadership and support. Delivery of effective treatments to populations experiencing co-occurring disorders that are underserved and undertreated are achievable in community-based clinical practices. This has implications for developing treatment capacity outside of hospital settings to enable treatment of co-occurring disorders to become more accessible.

There is a paucity of comparative literature on pathway to care among patients with co-occurring disorders and those with only substance use disorders. This paper aims to compare the pathways to care among patients with co-occurring disorder and those with only substance use disorders.

A cross-sectional observational study was carried out on male treatment seekers at a tertiary care substance use disorder treatment center in India. Participants were recruited in two groups, those with co-occurring psychiatric and substance use disorders and those with only substance use disorders. The two groups were matched for age and socio-economic status.

A total of 189 subjects with co-occurring psychiatric and substance use disorders and 197 subjects with substance use disorders only were recruited. Psychiatric services were the most common first point of care. However, a larger proportion of the subjects in the co-occurring disorder group received the first care from faith healers, while a greater proportion received first care from the therapeutic communities in substance use disorder only group. Initial care was sought mostly following suggestion from the family members in both the groups. The time to treatment for substance use disorders did not differ between the two groups, though the treatment seeking for substance use disorder was more delayed than that of psychiatric disorder in the co-occurring disorder group.

The findings shed light on the pathway of care followed in India and is a matter of further research.

Expansion of services and dissemination of information about psychiatric disorders and substance use disorders can provide timely care to patients with substance use disorders and co-occurring disorders.

The findings have a social implication as well. More awareness is needed currently in India for timely treatment of dual disorders.

The paper is an original research by the authors. The data were collected from the participants who reported to the dual diagnosis clinic. The findings are important as they tell us about the current understanding of dual diagnosis by the general public.

Borderline personality disorder (BPD) is a debilitating illness characterised by a pervasive pattern of emotional instability, interpersonal difficulties and impulsive behaviour in association with repeated self-injury and chronic suicidal ideation. People diagnosed with BPD also have high rates of co-occurring psychopathology, including disorders associated with disturbed impulse control, such as substance use disorder (SUD) and disordered eating behaviours. The co-occurrence of BPD and impulse control disorders contributes to the severity and complexity of clinical presentations and negatively impacts the course of treatment and recovery. This study qualitatively documents aspects of the lived experience and recovery journeys of people diagnosed with BPD and co-occurring SUD and/or disordered eating. This study aims to identify similarities with respect to themes reported at different stages of the recovery process, as well as highlight important factors that may hinder and/or foster recovery.

In-person, in-depth, semi-structured interviews were conducted with 12 specialist service consumers within a clinical setting. Ten women and two men (22–58 years; mean: 35.5 years) were recruited. Interview transcripts were analysed using thematic analysis principles.

As expected, participants with co-occurring disorders experienced severe forms of psychopathology. The lived experience descriptions aligned with the proposition that people with BPD engage in impulsive behaviours as a response to extreme emotional states. Key emergent themes and sub-themes relating to recovery comprised three domains: factors hindering adaptive change; factors assisting adaptive change and factors that constitute change. An inability to regulate negative affect appears to be an important underlying mechanism that links the three disorders.

This study highlights the potential shortcomings in the traditional approach of treating co-occurring disorders of BPD, SUD and eating disorders as separate diagnoses. The current findings strongly support the adoption of an integrative approach to treating complex mental health issues while concurrently emphasising social connection, support and general health and lifestyle changes.

The findings of this study contribute to the burgeoning BPD recovery literature. A feature of the current study was its use of in-depth face-to-face interviews, which provided rich, many layered, detailed and nuanced data, which is a major goal of qualitative research (Fusch and Ness, 2015). Furthermore, the interviews were conducted within a safe clinical setting with engagement facilitated by a clinically trained professional. There was also a genuine willingness among participants to share their stories in the belief that doing so would inform effective future clinical practice. Their willingness and engagement as participants may reflect their progress along the path to recovery in comparison to others with similar diagnoses. Finally, most of the interviewees were engaging in dialectical behavioural therapy (DBT)-style therapies; two were receiving mentalisation-based therapy treatment, and most had previously engaged in cognitive behavioural therapy or acceptance and commitment therapy-based approaches. The predominance of DBT-style therapy may have influenced the ways that themes were articulated. Future studies could supplement this area of research by interviewing participants receiving therapeutic interventions other than DBT for the treatment of BPD and heightened impulsivity.

The purpose of this paper is to explore and describe first-person experiences of relational recovery in co-occurring mental health and substance use conditions.

Within a phenomenological and collaborative approach, in-depth individual interviews with eight persons with co-occurring conditions were analysed using systematic text condensation.

Participants described interpersonal relationships as both supporting and hindering recovery in fundamental ways. Four categories of experiences of relational recovery were described as follows: choosing one’s child; living with loneliness and a painful past; sacrificing everything for one’s partner; and regaining trust and support.

This paper provides an enhanced understanding of how interpersonal relationships may be experienced by persons who live with co-occurring conditions. The results generally support an understanding of recovery as a relational process.

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) frequently co-occur (PTSD+SUD). The onset of these disorders often occurs during adolescence. There is limited understanding of the perspectives of service providers working with this population. The purpose of this paper is to identify the practices, attitudes, experiences and training needs of Australian service providers treating adolescents with PTSD+SUD.

Service providers in Australia were invited to complete an anonymous online survey regarding their experiences working with adolescents who have PTSD+SUD. Ninety participants completed the 48-item survey that comprised multiple choice and open-ended questions.

Service providers estimated that up to 60 per cent of their adolescent clients with PTSD also have SUD. They identified case management, engaging with caregivers and difficult client emotions as specific challenges associated with working with this population. Despite this, providers rated treating PTSD+SUD as highly gratifying for reasons such as teaching new coping skills, developing expertise and assisting clients to achieve their goals. There were mixed perspectives on how to best treat adolescents with PTSD+SUD, and all participants identified a need for evidence-based resources specific to this population.

This is the first survey of Australian service providers working with adolescents who experience PTSD+SUD. The findings improve our understanding of the challenges and rewards associated with working with this population, and provide valuable information that can enhance clinical training and guide the development of new treatment approaches for this common and debilitating comorbidity.

Past studies demonstrated the efficacy of integrated cognitive-behavioral therapy (CBT) for substance use disorder (SUD) and intimate partner violence (IPV) as well as high rates of depressive symptoms in this population. However, little is known about how depressive symptoms impact treatment outcomes. The authors hypothesized that integrated CBT, but not standard drug counseling (DC), would buffer the negative effects of depressive symptoms on treatment response.

A secondary analysis of a randomized trial compared men assigned to 12 weeks of integrated CBT for SUD and IPV (n = 29) to those in DC (n = 34).

Most (60%) of the sample reported any depressive symptoms. Controlling for baseline IPV, reporting any depressive symptoms was associated with more positive cocaine screens during treatment. Among men with depressive symptoms, integrated CBT but not DC was associated with fewer positive cocaine screens. Controlling for baseline alcohol variables, integrated CBT and depressive symptoms were each associated with less aggression outside of intimate relationships (family, strangers, etc.) during treatment. For men without depressive symptoms, integrated CBT was associated with less non-IPV aggression compared to DC. Effects were not significant for other substances, IPV, or at follow-up.

This study found some evidence for differential response to CBT by depressive symptoms on cocaine and aggression at end of treatment, which did not persist three months later. Future studies should explore mechanisms of integrated CBT for SUD and IPV, including mood regulation, on depressive symptoms in real-world samples.

Integrated CBT buffered depressive symptoms’ impact on cocaine use, yet only improved non-IPV aggression in men without depressive symptoms.

Although integrated CBT’s efficacy for improving SUD and IPV has been established, moderators of treatment response have not been investigated.

Sex and gender are regarded as critical structural determinants of mental health and mental illness. Mental illness is a complex phenomenon, and risky behaviour and substance use commonly occur simultaneously or subsequent to one another. A gendered vulnerability in biological, environmental, and behavioural risk factors has been registered in the development and escalation of mental illness. Studies have found that women who use drugs experience greater physical and mental health repercussions than men. Women who use drugs present higher rates of depression and anxiety, suicidal tendencies, isolation and general psychological distress. This chapter addresses the most common mental illnesses associated with women who use drugs: depression, anxiety, trauma-related disorders, and eating disorders.

Substance use disorders (SUDs) often co-occur with major depressive disorder (MDD), yet treatments targeting this comorbidity are limited, especially in resource limited settings where individuals with SUDs often receive treatment.

Based upon principles of reinforcement and behavioral economic models of substance use, as well as the Brief Behavioral Activation Treatment for Depression (BATD; Lejuez et al., 2011), the Life Enhancement Treatment for Substance Use (LETS ACT; Daughters et al., 2008) was developed to meet the unique needs of patients with MDD-SUD comorbidity.

The current manuscript presents a summary of the theoretical foundations and key components of LETS ACT.

A specific focus on increasing dissemination via the flexible delivery dependent on patient and treatment setting characteristics is provided throughout.

The purpose of this paper is to identify and report on the mental health needs of those attending substance misuse services (SMS) adhering to the diagnostic criteria as defined in DSM 5 with reference to common mental health disorders. It also examines differences in the numbers of appropriately trained cognitive behaviour therapy (CBT) therapists and highlights the lack of provision of CBT reflected in the much smaller number of accredited therapists in Wales compared to other parts of the UK.

This population was identified by way of an audit of data collected via the out-patient clinics conducted by the author.

The paper identifies a high proportion of patients who attended SMSs as having complex psychological need as a consequence of co-morbidity.

The results of the audit may have limitations but the implications from the findings suggest potential value in looking more at clinical outcomes following evidence-based psychological interventions.

A conclusion from the findings is suggested value in a more structured approach to looking at clinical outcomes.

This audit was undertaken in North Wales. There is no IAPT or matrix-structured Level II CBT training programmes available in Wales. The audit identifies the need for more evidence-based psychological interventions such as CBT linked to the development of such services. The apparent lack of political will to change the status quo is also highlighted as a problem.