mental health and substance abuse essay

When Substance Abuse and Psychiatric Issues Collide

Co-occurring disorders have taken a toll on celebrities and regular folk alike..

Updated April 5, 2024 | Reviewed by Hara Estroff Marano

• What Is Psychiatry?
• Find a therapist near me
• Many people have a substance use disorder (SUD) and serious psychiatric issue at the same time.
• Experts and the public have struggled with whether drugs caused psychiatric illness or vice versa.
• Carrie Fisher and Matthew Perry may have self-medicated over distress, or SUDs triggered psychiatric ills.
• Sexual, physical, or emotional traumatic events in childhood increase risks for co-occurring disorders.

Often starting in adolescence or young adulthood, many individuals have both a substance abuse disorder and at least one psychiatric disorder, although which diagnosis came first is frequently unclear. This “double trouble” problem is also called “co-occurring disorders (CODS),” as well as “concurrent disorders” and “dual diagnosis.”

The combination of disorders has been discussed in speculative articles about celebrities like Charlie Sheen, Demi Lovato, Justin Bieber, Jhene Aiko, Britney Spears, and Russell Brand. More in-depth scientific and biographic articles about Ernest Hemingway, Carrie Fisher, and Kurt Cobain have helped explain the complexity of CODs. Some of us were mesmerized and sad watching their struggles. Kurt Cobain’s lyrics, performance, and even some of his songs (like “Lithium” and “All Apologies” ) come to my mind as both a fan and a psychiatrist.

But it’s not just celebrities who are suffering from both substance abuse and mental health issues. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2022 , 21.5 million people in the United States had both a substance abuse disorder and a mental illness.

In the past, experts believed it was best to treat one disorder (usually the substance issue) and assumed any psychiatric issues would sort themselves out. However, if the psychiatric issue persisted, it was eventually treated.

In contrast, current thinking is both disorders should be treated in about the same time frame, because ignoring either could be problematic for the patient. If someone is severely depressed, anxious, or has another psychiatric disorder, it may be possible for them to detoxify from a substance, but it’s very hard to develop longer-term control over substance dependence and any accompanying mental illnesses when both issues are not addressed.

For adolescents and young adults with underlying psychiatric disorders, abusing substances provides an unfortunate early opportunity for incorporating bad learning. For example, if they struggle with anxiety , teens may discover that alcohol calms their nerves, making them less anxious about meeting new people or engaging in social interactions. Early self- medication of psychiatric symptoms is double trouble, as alcohol causes brain changes and effects that can trigger alcohol use disorder (AUD.) Some people describe the first drink as magical, that first taste feeling like the key to previously locked-out relief.

More Intense Treatment Is Needed with SUDs Combined with Psychiatric Diagnoses

Individuals diagnosed with co-occurring disorders often need more intense treatment than others due to the complexity of their cases. They also may face greater consequences from their substance abuse compared to patients diagnosed with a mental illness only. Examples of such possible consequences may include a greater exacerbation of their psychiatric symptoms, hallucinations and/or suicidal thinking, an increase in aggressive and violent behaviors, concurrent medical, nutritional, and infectious issues, more emergency room visits than other patients, and a greater number of falls and injuries.

Those with CODs are also more likely to experience head injuries and physical fights with others as well as sexually transmitted infections (STIs). Some have a greater frequency of involuntary inpatient psychiatric placements. These patients need a psychiatric assessment and treatment from experts in both addictions and psychiatry.

Possible Causes of CODs

One theory to explain CODS, the self-medication theory, was developed by the late Harvard psychiatrist and psychoanalyst Ed Khantzian, M.D. He assumed anhedonia (the inability to experience pleasure) or suffering in general was the driving force behind addiction. This theory hypothesizes that underlying psychological disorders compel individuals to self-medicate their feelings with alcohol and/or drugs. In addition, patients are sometimes distinguished by their drugs of choice. For instance, patients with an alcohol use disorder might have been battling social anxiety and self-medicating with alcohol for performance anxiety, shyness, or nervousness in social settings; stimulants such as cocaine or methamphetamine often are used by those with depression or untreated attentional disorders like attention deficit hyperactivity disorder (ADHD).

The self-medication hypothesis was first put forth in a 1985 cover article in the American Journal of Psychiatry. It focused on how and why individuals are drawn to and become dependent on drugs. The self-medication hypothesis was derived from clinical evaluation and treatment of thousands of patients spanning five decades and remains a credible theory.

As I have stated in the American Journal of Psychiatry , it is one of the most “intuitively appealing theories” about addiction. But drugs of abuse and addiction can also cause psychiatric illnesses by targeting the brain’s mood and pleasure systems and inadvertently undermining them.

Neuroscientist Kenneth Blum developed the theory of reward-deficiency syndrome (RDS) as the cause for co-occurring addictive disorders and psychiatric diagnoses. In many ways, RDS is a natural extension of Khantzian’s theory, but it’s an update, attributing the cause to an underlying dopamine deficiency or neurochemical dysfunction that supports drug-seeking/self-medication.

People with RDS, which may be inherited, are miserably unhappy and their lives may be intolerable due to their inability to gain satisfaction from work, relationships, or their accomplishments.

An emerging, newer approach of “preaddiction” as an early or moderate stage of substance abuse is championed by leaders of the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute of Mental Health (NIMH). Preaddiction is conceptually analogous to prediabetes, a risk factor for type-2 diabetes. Prediabetes has contributed to a quantum leap in early detection of people at risk for type-2 diabetes, shortened delays between symptom onset and treatment entry before the onset of diabetes, and overall been a remarkable success in halting progression to diabetes. Similarly, the earliest possible detection of substance abuse will save more lives as experts develop and focus on the evolving concept of preaddiction.

A Possible Environmental Cause: Adverse Childhood Events (ACEs)

In the late twentieth century, a large insurance provider in California worked with researchers to identify adverse childhood experiences (ACEs) that later reverberated in the lives of adults. The researchers found that individuals who reported the greatest numbers of ACEs—such as physical abuse, sexual abuse , loss of a biological parent, witnessing physical violence, and other severely traumatic childhood events—were significantly more likely than those with no ACEs to have psychiatric problems and substance abuse issues in adulthood. They were also at greater risk for suicidal behaviors.

Nirvana's Kurt Cobain was a person with bipolar disorder , substance use and a heroin habit, according to a cousin who described their family history in detail and noted that two uncles had killed themselves with guns. Cobain, who suicided in 1994, purportedly had at least four ACEs, including witnessing domestic violence , experiencing psychological abuse , being neglected, and suffering from his parents’ divorce . Such a score markedly increased Cobain’s risk for suicide as an adult.

Treatment of CODs Should Not Be Delayed

Although an extensive description of how CODs should best be treated is beyond the scope of this article, the key point is to not delay treatment of one disorder in favor of the other. Instead, as much of a simultaneous approach as possible is best. This often means a team of experts is needed, including a psychiatrist, psychologist, therapists, and others to assess the problem, determine whether inpatient, residential, or outpatient treatment is best, and develop a cohesive treatment plan for the patient.

In opioid use disorder treatment, the current standard of care is to focus on prevention of overdose and replacement of opioids with medication-assisted treatments (MATs.) However, detoxification from opioids or maintenance on a MAT would provide little symptomatic relief for a person with opioid use disorder, suicidal ideas, and bipolar illness.

It is also recommended to evaluate individuals for past or recent trauma and co-occurring psychiatric and medical illnesses and treat patients accordingly. Often this means psychotherapy is needed as well as psychiatric treatments. Psychotherapy may include cognitive behavioral therapy (CBT), motivation enhancement therapy (MET), dialectical behavior therapy (DBT), and other forms of therapy. Trained and experienced therapists are crucial. Depending on the substance on which patients depend, medication treatment for their detoxification, relapse prevention, and craving may or may not be available. Currently, medication treatments exist for tobacco use disorder, alcohol use disorder, and opioid use disorder.

Summing It Up

Not only celebrities but many people with a substance use disorder have at least one other psychiatric problem, and when this situation occurs, all disorders need to be identified and treated. I recommend professional help in checking for substance use disorders in psychiatric patients and also looking for psychiatric illness and a history of trauma in people with substance use disorders.

Future breakthroughs in genetic and other scientific research should make clearer why some individuals are more prone to such disorders, as well as lead experts toward the best medications, therapies, and other treatments to alleviate much more of this terrible suffering.

Cross, Charles R. Heavier than Heaven : a Biography of Kurt Cobain. New York :Hyperion, 2001.

Gold MS. Dual disorders: nosology, diagnosis, & treatment confusion--chicken or egg? Introduction. J Addict Dis. 2007;26 Suppl 1:1-3. doi: 10.1300/J069v26S01_01. PMID: 19283969.

Buckley PF, Brown ES. Prevalence and consequences of dual diagnosis. J Clin Psychiatry. 2006 Jul;67(7):e01. doi: 10.4088/jcp.0706e01. PMID: 17107226.

Mark S. Gold, M.D., is a pioneering researcher, professor, and chairman of psychiatry at Yale, the University of Florida, and Washington University in St Louis. His theories have changed the field, stimulated additional research, and led to new understanding and treatments for opioid use disorders, cocaine use disorders, overeating, smoking, and depression.

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Home — Essay Samples — Nursing & Health — Drug Addiction — Substance Abuse and Mental Health: A Connection

Substance Abuse and Mental Health: a Connection

• Categories: Drug Addiction Substance Abuse

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Words: 779 |

Published: Sep 12, 2023

Words: 779 | Pages: 2 | 4 min read

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The vicious cycle of co-occurrence, dual diagnosis and treatment challenges, the role of early intervention and prevention.

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Essay on Mental Health and Substance Use Disorder

INTRODUCTION

Mental health and substance use disorders are significant public health concerns that often co-occur with violence. In order to understand, address and improve concerns related to mental health and substance use disorders, it is critical to analyze perspectives of people who are affected and have sought help for substance use disorders. These people serve as service users of substance disorders. Any attempt to judge the experiences of health services without considering the experiences of people involved in their use would be incomplete. Through finding out what service users experience, drawing conclusions, and delivering a solution is made more accessible. This paper focuses on an individual’s life experiences (named Tyson) with severe substance use disorders and requires specialty treatment.

According to Canadian Center on Substance Use and Addiction (2014), a substance use disorder is characterized by clinically significant impairments in social functioning, health, and voluntary control over substance use. Substance use disorders range from mild to severe with respect to the severity and duration of their existence. Therefore, a mental illness is simply a disease/illness that changes a person’s thinking, behavior, and feelings and perhaps leads to distress and difficulty in functioning Canadian Center on Substance Use and Addiction (2014). Notably, a person with a mental illness does not necessarily look sick, especially when their condition is mild. This paper describes the critical components of a substance use disorder service user by determining their symptoms, challenges they incur, and the support the service users receive from SSW or MHAW considerations.

RECOGNIZING

We can all be sad or blue at some point in our lives; we have seen madmen and people of the kind in real life and movies and animations. This case presents an actual person with explicit symptoms of mental illness and substance use disorder such as confusion, agitation, and withdrawal. Other illnesses experienced by Tyson include schizophrenia, autism, depression, attention deficit hyperactivity disorder (ADHD), among other obsessive-compulsive disorders. However, it is essential to note that not all brain diseases are categorized as mental illness or substance use disorder. Neurological diseases such as epilepsy and Parkinson’s are brain disorders but do not qualify as mental illnesses Canadian Center on Substance Use and Addiction (2014).

Signs, symptoms, and behavior of Mental Health Illness

Each mental illness has its characteristics; however, there are some general warnings/conditions/behaviors that can alert you that a person requires a professional health check-up. According to the service user of a substance use disorder, the condition of mental wellbeing often changes and co-occur with issues related to substance use; these issues commonly intersect with trauma and violent experiences. That is, although the vast majority who have psychological well-being/substance use issues are not vicious, proof shows higher paces off at various times misuse and injury in their lives just as a current or on-going accomplice and non-accomplice animosity both as casualties and culprits, contrasted and people who do not have emotional well-being, or substance use issues.

Proof likewise shows that the two casualties and culprits of spousal maltreatment have more unfortunate emotional wellness than do the individuals who don’t encounter accomplice savagery. The co-event of psychological wellness, substance use, and savagery issues makes administration needs mind-boggling and requires exhaustive and facilitated care. To adjust administrations to the necessities of people who face issues, particularly the individuals who have simultaneous issues, analysts and experts require a superior comprehension of the encounters and points of view of individuals who have looked for help for just as the viewpoints of their relatives. Some mental health illness signs include;

• Marked personality change
• Excessive anger, violent or hostility behavior
• Prolonged depression and apathy
• Strange or grandiose ideas
• Excessive anxieties
• Mood swings which are extremely high or low
• Drug and alcohol abuse
• Inability to cope with problems and other daily activities
• The service user often talks about suicide or harming oneself
• Changes in sleeping and eating patterns

The above signs have great and psychological effects on Tyson, the service user, in a number of ways. For instance, the user’s daily chores are associated with very strange, impossible, and grandiose ideas such as exaggerating a lot about himself, his achievements, and his capabilities. Also, on many occasions, Tyson is spotted dismissing other people’s achievements and talents. Moreover, constant boasting and talking about himself brings irrelevancy to the service user.

If not enough, the service user experiences prolonged apathy and depression. This is categorized by Tyson’s disinterest in life activities and interactions with others. It has affected his ability to make friends, keep his duties and job well done, and no enjoyment of life at all cost. Tyson is not motivated to carry out his wellbeing, such as keeping neat and clean. Nevertheless, depression has reduced the quality of the user’s life with increased work and family problems. Today, Tyson is a low esteemed individual who underrates himself and finds isolation. Persistent depression and marked personality change have led to the following on service users;

• Loss of interest in day-by-day exercises
• Pity, void, or feeling down
• Sluggishness and absence of energy
• Low confidence, self-analysis, or feeling unfit
• Inconvenience thinking and instigating choices
• Crabbiness or unnecessary displeasure
• Diminished action, viability, and efficiency
• Evasion of social exercises
• Sensations of blame and stress over the past
• Helpless hunger or gorging
• Rest issues

Biggest challenges

• Social interaction

According to Tyson, my greatest challenge is acting or responding in a manner considered socially satisfactory, for example, not getting irritated, inpatient, or furious. Defeating trepidation and uneasiness when managing new individuals is additionally a test, and not closing down and going into defensive battle mode. Similarly, I battle to interface with individuals with whom I share little for all intents and purpose, and sometimes, I neglect to see the worth in that.

• Making yourself a priority.

At the point when things are going admirably, life disrupts everything – work, family, companions. I love every one of them, so saying no is hard. At the point when I become self-satisfied and stop my ordinary practices, it’s right around an assurance that my temperament will change and go downhill. Getting sufficient rest and taking a walk are necessities, regardless of how bustling I am and how acceptable I’m feeling.

• Identifying moods and feelings

A major test isn’t knowing whether I’m feeling is identified with my disease, side effects, or simply a piece of life. Due to an arrangement change at work, I have been on decreased hours. Subsequently, I thought it was not easy to persuade myself to work at home and be useful. Is this suggestive of my disease? Or then again, is it related to sensations of misfortune and uncertainty over my future, and consequently typical? I re-think myself a great deal as a result of my sickness.

• Maintaining good routines
• Reaching out
• Planning and navigating the world
• Living up to expectations

Social Service Worker’s (SSW) support

According to  The role of social work in mental health  (2019), most mental health settings remember administrations for three-wide degrees of medical care application: avoidance, therapy, and recovery. It is perceived that singular social specialists might rehearse only inside one defining or cross the limits of each of the three in light of assorted customer, family, and local area needs.

Plans to diminish the frequency of infection or brokenness in a populace through changing distressing conditions and reinforcing the capacity of the person to adapt. Counteraction includes the advancement and upkeep of good wellbeing through training, consideration regarding sufficient principles for fundamental requirements, and explicit security against known dangers.

Plans to diminish the pervasiveness (number of existing instances) of a problem or brokenness and incorporates early conclusion, mediation, and treatment. In psychological well-being settings, treatment exercises are centered around people encountering intense mental manifestations, passionate injury, relationship issues, stress, pain, or emergency and incorporate evaluation, hazard the executives, singular, couple, family and gathering directing, intercession or treatment and backing. Social work utilizes relationships as the premise.

• Rehabilitation:

Targets diminish the delayed consequences of confusion or brokenness and include the arrangement of administrations for pre-preparing and recovery to guarantee the person’s most extreme utilization of residual limits.

Specific to their employment setting, social workers in mental health deliver the following professional services:

• Direct services
• Case management
• Community development
• Supervision and consultation
• Program management and administration
• Research and evaluation
• Social action

Evidence-based interventions

The evidence-based treatment turned into a well-known expression during the 1990s as mental health came to esteem the utilization of the logical strategy. While psychological well-being customarily had depended on emotional reports of clinical adequacy, advisors and other psychological well-being experts started calling for thorough examinations to be done to decide the viability of medicines and how to execute the best. The practices that went through thorough testing and were demonstrated with clinical and logical proof became known as evidence-based. The high bar that was set with the emphasis on the logical technique has brought about a sensational expansion in the viability of treatment. We’re done depending on the mystery. Hitched with patient inclinations and an advisor’s encounter, evidence-based practices are important apparatuses that can be utilized with certainty. Examples of evidence-based interventions include;

• Cognitive Behavioral Therapy

Works by assisting individuals with recognizing and changing perplexing and dreary examples of reasoning imbued over numerous years, influencing feelings and driving conduct. CBT is an intercession strategy that changes the manner in which customers ponder themselves and their environmental elements  Health care systems and substance use disorders – Facing addiction in America  (2016).

• Dialectical behavior therapy

Dialectical behavior therapy is a cognitive behavioral therapy that gives a more prominent spotlight on friendly and enthusiastic components. It was created to approach to assist individuals with outrageous or shaky feelings and hurtful reckless practices.

• Exposure therapy
• Functional Family Therapy
• Assertive Community Treatment
• Motivational Interviewing

RECOVERY ORIENTATION

The recovery dimension-oriented practice includes the following;

• Creating a culture and language of hope

Recovery is workable for everybody. Expectation animates recovery, and gaining the capacities to support trust is the beginning stage for building an emotional wellness framework outfitted to cultivating recuperation (Gutierrez, 2020, P 220-223). In this sense, recovery is essentially about trust. This part contains a solitary, all-encompassing Rule that depicts how to convey positive assumptions and advance expectation and confidence to make an assistance culture and language that prompts an individual to feel esteemed, significant, invited, and safe.

• Recovery is personal

The key to recovery includes identifying each person’s uniqueness and their ability to determine their problem.

• Recovery occurs in the context of one’s life.
• Responding to the diverse needs of everyone living in Canada
• Recovery is about transforming services and systems.

Stigma and discrimination can make someone’s mental health worse. The best way to challenge this stigmatization is by doing the following.

• Talking about it openly and often.
• Educating oneself and others in the society (Gutierrez, 2020, P 227).
• Showing compassion to individuals with this problem.
• Encourage equality and equity.

Conclusively, mental illness is a manageable disease/disorder. Many individuals fall into the jaws of this menace due to lack of knowledge and space for expression. Creating a culture and language of hope is identified as various recovery procedures that assist in beating this disease. Moreover, adequate care and monitoring is advised to such individuals.

Canadian Center on Substance Use and Addiction (2014). Childhood And Adolescent Pathways To Substance Use Disorders.  https://www.ccsa.ca/childhood-and-adolescent-pathways-substanceuse-disorders-report .

Gutierrez, D., Crowe, A., Mullen, P. R., Pignato, L., & Fan, S. (2020). Stigma, Help Seeking, and Substance Use. Professional Counselor, 10(2), 220–234.

Health care systems and substance use disorders – Facing addiction in America – NCBI bookshelf . (2016). National Center for Biotechnology Information.  https://www.ncbi.nlm.nih.gov/books/NBK424848/

The role of social work in mental health . (2019, October 21). Canadian Association of Social Workers.  https://www.casw-acts.ca/en/role-social-work-mental-health .

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Common Comorbidities with Substance Use Disorders Research Report Why is there comorbidity between substance use disorders and mental illnesses?

The high prevalence of comorbidity between substance use disorders and other mental illnesses does not necessarily mean that one caused the other, even if one appeared first. Establishing causality or directionality is difficult for several reasons. For example, behavioral or emotional problems may not be severe enough for a diagnosis (called subclinical symptoms), but subclinical mental health issues may prompt drug use. Also, people’s recollections of when drug use or addiction started may be imperfect, making it difficult to determine whether the substance use or mental health issues came first.

Three main pathways can contribute to the comorbidity between substance use disorders and mental illnesses: 1

• Common risk factors can contribute to both mental illness and substance use and addiction.
• Mental illness may contribute to substance use and addiction.
• Substance use and addiction can contribute to the development of mental illness.

1. Common risk factors can contribute to both mental illness and substance use and addiction.

Both substance use disorders and other mental illnesses are caused by overlapping factors such as genetic and epigenetic vulnerabilities, 27,33–35 issues with similar areas of the brain, 2,3,36 and environmental influences such as early exposure to stress or trauma. 3,27

Genetic Vulnerabilities

It is estimated that 40–60 percent of an individual’s vulnerability to substance use disorders is attributable to genetics. 37 An active area of comorbidity research involves the search for that might predispose individuals to develop both a substance use disorder and other mental illnesses, or to have a greater risk of a second disorder occurring after the first appears. 27,33,34 Most of this vulnerability arises from complex interactions among multiple genes and genetic interactions with environmental influences. 33,38 For example, frequent marijuana use during adolescence is associated with increased risk of psychosis in adulthood, specifically among individuals who carry a particular gene variant. 25–2 7

In some instances, a gene product may act directly, as when a protein influences how a person responds to a drug (e.g., whether the drug experience is pleasurable or not) or how long a drug remains in the body. Specific genetic factors have been identified that predispose an individual to alcohol dependence and cigarette smoking, and research is starting to uncover the link between genetic sequences and a higher risk of cocaine dependence, heavy opioid use, and cannabis craving and withdrawal. 37 But genes can also act indirectly by altering how an individual responds to stress 38 or by increasing the likelihood of risk-taking and novelty-seeking behaviors, 3 which could influence the initiation of substance use as well as the development of substance use disorders and other mental illnesses. Research suggests that there are many genes that may contribute to the risk for both mental disorders and addiction, including those that influence the action of neurotransmitters—chemicals that carry messages from one neuron to another—that are affected by drugs and commonly dysregulated in mental illness, such as dopamine and serotonin. 33,39

Epigenetic Influences

Scientists are also beginning to understand the very powerful ways that genetic and environmental factors interact at the molecular level. 40,41 Epigenetics refers to the study of changes in the regulation of gene activity and expression that are not dependent on gene sequence; that is, changes that affect how genetic information is read and acted on by cells in the body. Environmental factors such as chronic stress, trauma, or drug exposure can induce stable changes in gene expression, which can alter functioning in neural circuits and ultimately impact behavior. 42 For more information on epigenetics, see Genetics and Epigenetics of Addiction DrugFacts .

Through epigenetic mechanisms, the environment can cause long-term genetic adaptations—influencing the pattern of genes that are active or silent in encoding proteins—without altering the DNA sequence. These modifications can sometimes even be passed down to the next generation. 35 There is also evidence that they can be reversed with interventions or environmental alteration. 41

The epigenetic impact of environment is highly dependent on developmental stage. 42 Studies suggest that environmental factors interact with genetic vulnerability during particular developmental periods to increase the risk for mental illnesses 42 and addiction. 35 For example, animal studies indicate that a maternal diet high in fat during pregnancy can influence levels of key proteins involved in neurotransmission in the brain’s reward pathway. 41 Other animal research has shown that poor quality maternal care diminished the ability of offspring to respond to stress through epigenetic mechanisms. 41 Researchers are using animal models to explore the epigenetic changes induced by chronic stress or drug administration, and how these changes contribute to depression- and addiction-related behaviors. 40 A better understanding of the biological mechanisms that underlie the genetic and biological interactions that contribute to the development of these disorders will inform the design of improved treatment strategies. 40,42

Brain Region Involvement

Many areas of the brain are affected by both substance use disorders and other mental illnesses. For example, the circuits in the brain that mediate reward, decision making, impulse control, and emotions may be affected by addictive substances and disrupted in substance use disorders, depression, schizophrenia, and other psychiatric disorders. 2,3,34,43 In addition, multiple neurotransmitter systems have been implicated in both substance use disorders and other mental disorders including, but not limited to, dopamine, 44–46 serotonin, 47,48 glutamate, 49,50 GABA, 51 and norepinephrine. 46,52,53

Environmental Influences

Many environmental factors are associated with an increased risk for both substance use disorders and mental illness including chronic stress, trauma, and adverse childhood experiences, among others. Many of these factors are modifiable and; thus, prevention interventions will often result in reductions in both substance use disorders and mental illness, as discussed in the Surgeon General’s report on alcohol, drugs, and health.

Stress is a known risk factor for a range of mental disorders and therefore provides one likely common neurobiological link between the disease processes of substance use disorders and mental disorders. 3,38,54 Exposure to stressors is also a major risk factor for relapse to drug use after periods of recovery. Stress responses are mediated through the hypothalamic-pituitary-adrenal (HPA) axis, which in turn can influence brain circuits that control motivation. Higher levels of stress have been shown to reduce activity in the prefrontal cortex and increase responsivity in the striatum, which leads to decreased behavioral control and increased impulsivity. 55   Early life stress and chronic stress can cause long-term alterations in the HPA axis, which affects limbic brain circuits that are involved in motivation, learning, and adaptation, and are impaired in individuals with substance use disorders and other mental illnesses. 2,3,34,43

Importantly, dopamine pathways have been implicated in the way in which stress can increase vulnerability to substance use disorders. HPA axis hyperactivity has been shown to alter dopamine signaling, which may enhance the reinforcing properties of drugs. 38,54,55 In turn, substance use causes changes to many neurotransmitter systems that are involved in responses to stress. These neurobiological changes are thought to underlie the link between stress and escalation of drug use as well as relapse. Treatments that target stress, such as mindfulness-based stress reduction, have been shown to be beneficial for reducing depression, anxiety, and substance use. 56

Trauma and Adverse Childhood Experiences

Physically or emotionally traumatized people are at much higher risk for drug use and SUDs. 57 and the co-occurrence of these disorders is associated with inferior treatment outcomes. 57 People with PTSD may use substances in an attempt to reduce their anxiety and to avoid dealing with trauma and its consequences. 58

The link between substance use disorder and PTSD is of particular concern for service members returning from tours of duty in Iraq and Afghanistan. Between 2004 and 2010, approximately 16 percent of veterans had an untreated substance use disorder, and 8 percent needed treatment for serious psychological distress (SPD). 59 Data from a survey that used a contemporary, national sample of veterans estimated that the rate of lifetime PTSD was 8 percent, while approximately 5 percent reported current PTSD. 60 Approximately 1 in 5 veterans with PTSD also has a co-occurring substance use disorder. 61

2. Mental illnesses can contribute to drug use and addiction.

Certain mental disorders are established risk factors for developing a substance use disorder. 62 It is commonly hypothesized that individuals with severe, mild, or even subclinical mental disorders may use drugs as a form of self-medication. 1,28 Although some drugs may temporarily reduce symptoms of a mental illness, they can also exacerbate symptoms, both acutely and in the long run. For example, evidence suggests that periods of cocaine use may worsen the symptoms of bipolar disorder and contribute to progression of this illness. 63  

When an individual develops a mental illness, associated changes in brain activity may increase the vulnerability for problematic use of substances by enhancing their rewarding effects, reducing awareness of their negative effects, or alleviating the unpleasant symptoms of the mental disorder or the side effects of the medication used to treat it. 1 For example, neuroimaging suggests that ADHD is associated with neurobiological changes in brain circuits that are also associated with drug cravings, perhaps partially explaining why patients with substance use disorders report greater cravings when they have comorbid ADHD. 64–66

3. Substance use and addiction can contribute to the development of mental illness.

Substance use can lead to changes in some of the same brain areas that are disrupted in other mental disorders, such as schizophrenia, anxiety, mood, or impulse-control disorders. 2,36 Drug use that precedes the first symptoms of a mental illness may produce changes in brain structure and function that kindle an underlying predisposition to develop that mental illness.

The Comorbidity Between Mental Illness and Tobacco Use—Highlight on Schizophrenia

Smoking may reduce or help individuals cope with the symptoms of these illnesses, such as poor concentration, low mood, and stress. 43,67,68 Such alleviation of symptoms may explain why people with mental illnesses are less likely to quit smoking compared with those in the general population. 68,71,72 Unfortunately, high rates of smoking and difficulty quitting among people with schizophrenia may contribute to their greater prevalence of cardiovascular disease and shorter life expectancy. 68

Research on Schizophrenia and Nicotine

Research on how both nicotine and schizophrenia affect the brain has generated other possible explanations for the high rate of smoking among people with schizophrenia. 43 The presence of abnormalities in particular circuits of the brain may predispose individuals to schizophrenia and increase the rewarding effects of drugs like nicotine, and/or reduce an individual’s ability to quit smoking. 43,73 These mechanisms are consistent with the observation that both nicotine and the medication clozapine (which also acts at nicotinic acetylcholine receptors, among others) are effective in treating individuals with schizophrenia, 17,74 and can serve as replacements for the nicotine obtained through cigarette smoking, thus making it easier to quit smoking. 74

The dorsal anterior cingulate cortex (dACC) is involved in decision-making and planning, focusing attention, and controlling impulses and emotions. Researchers have found that connections between this region and several other brain areas—including some involved in memory, emotion, and reward—are weaker among patients with schizophrenia compared with those without the disorder. This circuit was impaired among people with schizophrenia regardless of whether they smoked or not, as well as among the close relatives of people with schizophrenia. Several of these neural circuits were also less active among individuals with severe nicotine use disorder, suggesting that this brain circuit is impaired in both schizophrenia and nicotine dependence. 73

A lower level of nicotinic acetylcholine receptors is a neurobiological hallmark of schizophrenia. These receptors, which are involved in cognition and memory, 75 are naturally activated by the neurotransmitter acetylcholine—but they can also be activated by nicotine. Researchers are working to develop medications that stimulate these specific receptors, which can counter the cognitive impairments associated with schizophrenia without the addictive potential of nicotine or the negative health consequences of smoking. 75 Understanding how and why patients with schizophrenia use nicotine may help inform the development of new treatments for both schizophrenia and nicotine dependence.

Although there is a great need for new treatments for both schizophrenia and nicotine dependence, people with these comorbid disorders can quit without worsening their mental health when they have appropriate support. 67,76 For example, bupropion increases smoking abstinence rates in people with schizophrenia, with no apparent worsening of psychotic symptoms. 77,78 Adding motivational incentives (rewarding patients for biologically verified abstinence) to bupropion medication may help prevent relapse during the initial phase of smoking cessation. 78 Varenicline may also improve smoking cessation rates in schizophrenia, but this medication may worsen psychiatric symptoms and requires additional research. 78,79

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• April 01, 2024 | VOL. 181, NO. 4 CURRENT ISSUE pp.255-346
• March 01, 2024 | VOL. 181, NO. 3 pp.171-254
• February 01, 2024 | VOL. 181, NO. 2 pp.83-170
• January 01, 2024 | VOL. 181, NO. 1 pp.1-82

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Substance Use Disorders and Addiction: Mechanisms, Trends, and Treatment Implications

• Ned H. Kalin , M.D.

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The numbers for substance use disorders are large, and we need to pay attention to them. Data from the 2018 National Survey on Drug Use and Health ( 1 ) suggest that, over the preceding year, 20.3 million people age 12 or older had substance use disorders, and 14.8 million of these cases were attributed to alcohol. When considering other substances, the report estimated that 4.4 million individuals had a marijuana use disorder and that 2 million people suffered from an opiate use disorder. It is well known that stress is associated with an increase in the use of alcohol and other substances, and this is particularly relevant today in relation to the chronic uncertainty and distress associated with the COVID-19 pandemic along with the traumatic effects of racism and social injustice. In part related to stress, substance use disorders are highly comorbid with other psychiatric illnesses: 9.2 million adults were estimated to have a 1-year prevalence of both a mental illness and at least one substance use disorder. Although they may not necessarily meet criteria for a substance use disorder, it is well known that psychiatric patients have increased usage of alcohol, cigarettes, and other illicit substances. As an example, the survey estimated that over the preceding month, 37.2% of individuals with serious mental illnesses were cigarette smokers, compared with 16.3% of individuals without mental illnesses. Substance use frequently accompanies suicide and suicide attempts, and substance use disorders are associated with a long-term increased risk of suicide.

Addiction is the key process that underlies substance use disorders, and research using animal models and humans has revealed important insights into the neural circuits and molecules that mediate addiction. More specifically, research has shed light onto mechanisms underlying the critical components of addiction and relapse: reinforcement and reward, tolerance, withdrawal, negative affect, craving, and stress sensitization. In addition, clinical research has been instrumental in developing an evidence base for the use of pharmacological agents in the treatment of substance use disorders, which, in combination with psychosocial approaches, can provide effective treatments. However, despite the existence of therapeutic tools, relapse is common, and substance use disorders remain grossly undertreated. For example, whether at an inpatient hospital treatment facility or at a drug or alcohol rehabilitation program, it was estimated that only 11% of individuals needing treatment for substance use received appropriate care in 2018. Additionally, it is worth emphasizing that current practice frequently does not effectively integrate dual diagnosis treatment approaches, which is important because psychiatric and substance use disorders are highly comorbid. The barriers to receiving treatment are numerous and directly interact with existing health care inequities. It is imperative that as a field we overcome the obstacles to treatment, including the lack of resources at the individual level, a dearth of trained providers and appropriate treatment facilities, racial biases, and the marked stigmatization that is focused on individuals with addictions.

This issue of the Journal is focused on understanding factors contributing to substance use disorders and their comorbidity with psychiatric disorders, the effects of prenatal alcohol use on preadolescents, and brain mechanisms that are associated with addiction and relapse. An important theme that emerges from this issue is the necessity for understanding maladaptive substance use and its treatment in relation to health care inequities. This highlights the imperative to focus resources and treatment efforts on underprivileged and marginalized populations. The centerpiece of this issue is an overview on addiction written by Dr. George Koob, the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and coauthors Drs. Patricia Powell (NIAAA deputy director) and Aaron White ( 2 ). This outstanding article will serve as a foundational knowledge base for those interested in understanding the complex factors that mediate drug addiction. Of particular interest to the practice of psychiatry is the emphasis on the negative affect state “hyperkatifeia” as a major driver of addictive behavior and relapse. This places the dysphoria and psychological distress that are associated with prolonged withdrawal at the heart of treatment and underscores the importance of treating not only maladaptive drug-related behaviors but also the prolonged dysphoria and negative affect associated with addiction. It also speaks to why it is crucial to concurrently treat psychiatric comorbidities that commonly accompany substance use disorders.

Insights Into Mechanisms Related to Cocaine Addiction Using a Novel Imaging Method for Dopamine Neurons

Cassidy et al. ( 3 ) introduce a relatively new imaging technique that allows for an estimation of dopamine integrity and function in the substantia nigra, the site of origin of dopamine neurons that project to the striatum. Capitalizing on the high levels of neuromelanin that are found in substantia nigra dopamine neurons and the interaction between neuromelanin and intracellular iron, this MRI technique, termed neuromelanin-sensitive MRI (NM-MRI), shows promise in studying the involvement of substantia nigra dopamine neurons in neurodegenerative diseases and psychiatric illnesses. The authors used this technique to assess dopamine function in active cocaine users with the aim of exploring the hypothesis that cocaine use disorder is associated with blunted presynaptic striatal dopamine function that would be reflected in decreased “integrity” of the substantia nigra dopamine system. Surprisingly, NM-MRI revealed evidence for increased dopamine in the substantia nigra of individuals using cocaine. The authors suggest that this finding, in conjunction with prior work suggesting a blunted dopamine response, points to the possibility that cocaine use is associated with an altered intracellular distribution of dopamine. Specifically, the idea is that dopamine is shifted from being concentrated in releasable, functional vesicles at the synapse to a nonreleasable cytosolic pool. In addition to providing an intriguing alternative hypothesis underlying the cocaine-related alterations observed in substantia nigra dopamine function, this article highlights an innovative imaging method that can be used in further investigations involving the role of substantia nigra dopamine systems in neuropsychiatric disorders. Dr. Charles Bradberry, chief of the Preclinical Pharmacology Section at the National Institute on Drug Abuse, contributes an editorial that further explains the use of NM-MRI and discusses the theoretical implications of these unexpected findings in relation to cocaine use ( 4 ).

Treatment Implications of Understanding Brain Function During Early Abstinence in Patients With Alcohol Use Disorder

Developing a better understanding of the neural processes that are associated with substance use disorders is critical for conceptualizing improved treatment approaches. Blaine et al. ( 5 ) present neuroimaging data collected during early abstinence in patients with alcohol use disorder and link these data to relapses occurring during treatment. Of note, the findings from this study dovetail with the neural circuit schema Koob et al. provide in this issue’s overview on addiction ( 2 ). The first study in the Blaine et al. article uses 44 patients and 43 control subjects to demonstrate that patients with alcohol use disorder have a blunted neural response to the presentation of stress- and alcohol-related cues. This blunting was observed mainly in the ventromedial prefrontal cortex, a key prefrontal regulatory region, as well as in subcortical regions associated with reward processing, specifically the ventral striatum. Importantly, this finding was replicated in a second study in which 69 patients were studied in relation to their length of abstinence prior to treatment and treatment outcomes. The results demonstrated that individuals with the shortest abstinence times had greater alterations in neural responses to stress and alcohol cues. The authors also found that an individual’s length of abstinence prior to treatment, independent of the number of days of abstinence, was a predictor of relapse and that the magnitude of an individual’s neural alterations predicted the amount of heavy drinking occurring early in treatment. Although relapse is an all too common outcome in patients with substance use disorders, this study highlights an approach that has the potential to refine and develop new treatments that are based on addiction- and abstinence-related brain changes. In her thoughtful editorial, Dr. Edith Sullivan from Stanford University comments on the details of the study, the value of studying patients during early abstinence, and the implications of these findings for new treatment development ( 6 ).

Relatively Low Amounts of Alcohol Intake During Pregnancy Are Associated With Subtle Neurodevelopmental Effects in Preadolescent Offspring

Excessive substance use not only affects the user and their immediate family but also has transgenerational effects that can be mediated in utero. Lees et al. ( 7 ) present data suggesting that even the consumption of relatively low amounts of alcohol by expectant mothers can affect brain development, cognition, and emotion in their offspring. The researchers used data from the Adolescent Brain Cognitive Development Study, a large national community-based study, which allowed them to assess brain structure and function as well as behavioral, cognitive, and psychological outcomes in 9,719 preadolescents. The mothers of 2,518 of the subjects in this study reported some alcohol use during pregnancy, albeit at relatively low levels (0 to 80 drinks throughout pregnancy). Interestingly, and opposite of that expected in relation to data from individuals with fetal alcohol spectrum disorders, increases in brain volume and surface area were found in offspring of mothers who consumed the relatively low amounts of alcohol. Notably, any prenatal alcohol exposure was associated with small but significant increases in psychological problems that included increases in separation anxiety disorder and oppositional defiant disorder. Additionally, a dose-response effect was found for internalizing psychopathology, somatic complaints, and attentional deficits. While subtle, these findings point to neurodevelopmental alterations that may be mediated by even small amounts of prenatal alcohol consumption. Drs. Clare McCormack and Catherine Monk from Columbia University contribute an editorial that provides an in-depth assessment of these findings in relation to other studies, including those assessing severe deficits in individuals with fetal alcohol syndrome ( 8 ). McCormack and Monk emphasize that the behavioral and psychological effects reported in the Lees et al. article would not be clinically meaningful. However, it is feasible that the influences of these low amounts of alcohol could interact with other predisposing factors that might lead to more substantial negative outcomes.

Increased Comorbidity Between Substance Use and Psychiatric Disorders in Sexual Identity Minorities

There is no question that victims of societal marginalization experience disproportionate adversity and stress. Evans-Polce et al. ( 9 ) focus on this concern in relation to individuals who identify as sexual minorities by comparing their incidence of comorbid substance use and psychiatric disorders with that of individuals who identify as heterosexual. By using 2012−2013 data from 36,309 participants in the National Epidemiologic Study on Alcohol and Related Conditions–III, the authors examine the incidence of comorbid alcohol and tobacco use disorders with anxiety, mood disorders, and posttraumatic stress disorder (PTSD). The findings demonstrate increased incidences of substance use and psychiatric disorders in individuals who identified as bisexual or as gay or lesbian compared with those who identified as heterosexual. For example, a fourfold increase in the prevalence of PTSD was found in bisexual individuals compared with heterosexual individuals. In addition, the authors found an increased prevalence of substance use and psychiatric comorbidities in individuals who identified as bisexual and as gay or lesbian compared with individuals who identified as heterosexual. This was most prominent in women who identified as bisexual. For example, of the bisexual women who had an alcohol use disorder, 60.5% also had a psychiatric comorbidity, compared with 44.6% of heterosexual women. Additionally, the amount of reported sexual orientation discrimination and number of lifetime stressful events were associated with a greater likelihood of having comorbid substance use and psychiatric disorders. These findings are important but not surprising, as sexual minority individuals have a history of increased early-life trauma and throughout their lives may experience the painful and unwarranted consequences of bias and denigration. Nonetheless, these findings underscore the strong negative societal impacts experienced by minority groups and should sensitize providers to the additional needs of these individuals.

Trends in Nicotine Use and Dependence From 2001–2002 to 2012–2013

Although considerable efforts over earlier years have curbed the use of tobacco and nicotine, the use of these substances continues to be a significant public health problem. As noted above, individuals with psychiatric disorders are particularly vulnerable. Grant et al. ( 10 ) use data from the National Epidemiologic Survey on Alcohol and Related Conditions collected from a very large cohort to characterize trends in nicotine use and dependence over time. Results from their analysis support the so-called hardening hypothesis, which posits that although intervention-related reductions in nicotine use may have occurred over time, the impact of these interventions is less potent in individuals with more severe addictive behavior (i.e., nicotine dependence). When adjusted for sociodemographic factors, the results demonstrated a small but significant increase in nicotine use from 2001–2002 to 2012–2013. However, a much greater increase in nicotine dependence (46.1% to 52%) was observed over this time frame in individuals who had used nicotine during the preceding 12 months. The increases in nicotine use and dependence were associated with factors related to socioeconomic status, such as lower income and lower educational attainment. The authors interpret these findings as evidence for the hardening hypothesis, suggesting that despite the impression that nicotine use has plateaued, there is a growing number of highly dependent nicotine users who would benefit from nicotine dependence intervention programs. Dr. Kathleen Brady, from the Medical University of South Carolina, provides an editorial ( 11 ) that reviews the consequences of tobacco use and the history of the public measures that were initially taken to combat its use. Importantly, her editorial emphasizes the need to address health care inequity issues that affect individuals of lower socioeconomic status by devoting resources to develop and deploy effective smoking cessation interventions for at-risk and underresourced populations.

Conclusions

Maladaptive substance use and substance use disorders are highly prevalent and are among the most significant public health problems. Substance use is commonly comorbid with psychiatric disorders, and treatment efforts need to concurrently address both. The papers in this issue highlight new findings that are directly relevant to understanding, treating, and developing policies to better serve those afflicted with addictions. While treatments exist, the need for more effective treatments is clear, especially those focused on decreasing relapse rates. The negative affective state, hyperkatifeia, that accompanies longer-term abstinence is an important treatment target that should be emphasized in current practice as well as in new treatment development. In addition to developing a better understanding of the neurobiology of addictions and abstinence, it is necessary to ensure that there is equitable access to currently available treatments and treatment programs. Additional resources must be allocated to this cause. This depends on the recognition that health care inequities and societal barriers are major contributors to the continued high prevalence of substance use disorders, the individual suffering they inflict, and the huge toll that they incur at a societal level.

Disclosures of Editors’ financial relationships appear in the April 2020 issue of the Journal .

1 US Department of Health and Human Services: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality: National Survey on Drug Use and Health 2018. Rockville, Md, SAMHSA, 2019 ( https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2018-NSDUH ) Google Scholar

2 Koob GF, Powell P, White A : Addiction as a coping response: hyperkatifeia, deaths of despair, and COVID-19 . Am J Psychiatry 2020 ; 177:1031–1037 Link ,  Google Scholar

3 Cassidy CM, Carpenter KM, Konova AB, et al. : Evidence for dopamine abnormalities in the substantia nigra in cocaine addiction revealed by neuromelanin-sensitive MRI . Am J Psychiatry 2020 ; 177:1038–1047 Link ,  Google Scholar

4 Bradberry CW : Neuromelanin MRI: dark substance shines a light on dopamine dysfunction and cocaine use (editorial). Am J Psychiatry 2020 ; 177:1019–1021 Abstract ,  Google Scholar

5 Blaine SK, Wemm S, Fogelman N, et al. : Association of prefrontal-striatal functional pathology with alcohol abstinence days at treatment initiation and heavy drinking after treatment initiation . Am J Psychiatry 2020 ; 177:1048–1059 Link ,  Google Scholar

6 Sullivan EV : Why timing matters in alcohol use disorder recovery (editorial). Am J Psychiatry 2020 ; 177:1022–1024 Abstract ,  Google Scholar

7 Lees B, Mewton L, Jacobus J, et al. : Association of prenatal alcohol exposure with psychological, behavioral, and neurodevelopmental outcomes in children from the Adolescent Brain Cognitive Development Study . Am J Psychiatry 2020 ; 177:1060–1072 Link ,  Google Scholar

8 McCormack C, Monk C : Considering prenatal alcohol exposure in a developmental origins of health and disease framework (editorial). Am J Psychiatry 2020 ; 177:1025–1028 Abstract ,  Google Scholar

9 Evans-Polce RJ, Kcomt L, Veliz PT, et al. : Alcohol, tobacco, and comorbid psychiatric disorders and associations with sexual identity and stress-related correlates . Am J Psychiatry 2020 ; 177:1073–1081 Abstract ,  Google Scholar

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11 Brady KT : Social determinants of health and smoking cessation: a challenge (editorial). Am J Psychiatry 2020 ; 177:1029–1030 Abstract ,  Google Scholar

• Cited by None

• Substance-Related and Addictive Disorders
• Addiction Psychiatry
• Transgender (LGBT) Issues

Substance Abuse and Mental Illnesses

This essay will explore the link between substance abuse and mental illnesses. It will discuss how one can lead to or exacerbate the other, the challenges in treatment, and the importance of addressing both concurrently. Moreover, at PapersOwl, there are additional free essay samples connected to Addiction.

How it works

One of the world’s largest and most dangerous epidemics is the raging addiction to illegal drugs and substance abuse. A 2014 study showed that more than 21 million American citizens 12 years of age and older struggle with a substance use disorder. There are many different conceptions of what it means to have an addiction, and while everyone has the right to their own opinion, the true scientific definition of addiction is: “Addiction is a complex disease of the brain and the body that involves a compulsive use of one or more substances despite serious health and social consequences” (Center on Addiction).

Although addition can be defined, I believe that you can never truly understand the effects addiction has on the mind and body of an individual, until you personally experience it take over the life of someone you care or love. Many develop an addiction to a certain drug, to alter their minds. Being addicted to a drug, means that person has a grave dependence physically as well as pscyhologically, to that substance. The concept of addiction has been around for age, but just in the last 50-60 years experts have proven what addiction is and why it occurs. Often times addition it is said to be caused from a chemical imbalance in the brain, not allowing individuals to be able to regulate their manipulation of alcohol and/or drugs to a professionally prescribed dose. No one person in this world is the same therefore, there is no one specific way for addiction to begin. In some instances, as soon as an individual takes their first hit of a drug or sip of alcohol, they could potentially be addicted. Others could use the drug or alcohol occasionally for a period of time before a dependence is developed. The unknown, individualized reaction and addiction potential is what further complicates the issue.

The two most widely used and addictive, age-legal substances are alcohol and nicotine. However, illegal drugs are usually the most dangerous, since they are largely man made and can be tampered with at any stage of the manufacturing, distributing, or selling process. Often times, addiction starts out with prescription painkillers being given to individuals by their doctors, usually after a bad injury or surgery, for legitimate use. Users can then become dependent on the pills. When the time comes and the doctor stops prescribing them and cuts them off, it is often to late. In these situations, individuals are now addicted and still need the substance in their system, thus forcing them to turn to the “street drugs”, which are much more unknown and dangerous. The most common drug addicts use to replace prescription painkillers is heroin, because it is also a drug that triggers the brain’s opioid receptors and therefore radiates the same effect as the pain pills. When the opioid receptors are activated, it causes a decrease in pain, giving the individual an “out-of-body” sensation, and sends them into a state of euphoria. A study was taken in 2014 that showed around 586,000 Americans 11 years of age and older were able to be classified with a heroin use disorder. Unfortunately, 10,000 individuals lost their lives to fatal heroin overdose in that same year. Since 2014 the numbers of overdoses has continued to rise each year.

Addiction is most definitely a disease that can be cured, but it is not an easy process at all. The most efficient way to treat an addiction problem and prevent relapses is through a mixture of behavioral therapy and medication. The biggest hurdle is each recovery treatment has to be altered to cater to every different patient’s drug use patterns, their medical and psychiatric problems, as well as problems with their environment and social groups. Sadly, the recovery process and rehabilitation centers are not easily affordable, especially since in most cases most addicts are unemployed with little to no money, and oftentimes homeless. Another factor that makes addicts weary to get off the drugs is the withdrawal they go through. A few of the symptoms drug users will experience are flu like symptoms, depression, anxiety, insomnia, tremors, body aches, and even seizures. Depending on the type of drug, the method of drug use whether it be swallowing, smoking, snorting, or injecting, how long the individual has been using, and a few different other factors determines how severe the symptoms are and how long they will last. In some of the extreme cases certain symptoms can last up to several months.

Mental illness is another disease just like addiction, that is largely widespread and very common throughout the United States. It has been proven that roughly 54 million Americans endure some form of mental illness in any given year. “Mental illness is a disease that causes mild to severe disturbances in thought and/or behavior, resulting in an inability to cope with life’s ordinary demands and routines” (Mental Health America). There is not just one generic form of mental illness. Every single individual is different and each brain’s composition processes things differently. There are currently over 200 forms of mental illnesses and with those, everyone’s symptoms are always different. Like with everything, there are ones that are more common in a population, and others that are more extensive and unique. Some of the most common mental illnesses include depression, anxiety disorders, bipolar disorder, dementia, and schizophrenia. There is an abundance of factors that can cause an individual to develop a mental illness, and not just one incident will cause it. Mental disorders can be formed from an excessive amount of stress from a series of events or one specific event, environmental stresses, genetic factors, or biochemical imbalances.

Out of the handful of more common disorders, depression is the one illness that is the most common and diverse throughout the country. Even though it is very common, that does not take away from just how serious this disorder can be. Depression is a severe mood disorder, that will affect the way an individual thinks and feels. This disease also makes ordinary, day-to-day activities such as sleeping, getting out of bed, working, and even eating, much harder. Just like with the many different forms of mental illnesses, there is a number of different forms of depression. The different types include persistent depressive disorder, also known as dysthymia. This type of depression is described and diagnosed by a depressed mood that lasts for at least two years. Postpartum depression is periods of “full-blown major depression during pregnancy or after delivery” (National Institute of Mental Illness). This particular disorder makes it very challenging for new mothers to carry out their duties. Psychotic depression comes about when an individual is experiencing symptoms of a full-blown depression period along with a form of psychosis, “such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations)” (National Institute of Mental Illness). Another form of depression is the seasonal affective disorder. This type of depression is diagnosed when the symptoms of depression activate during the winter months. This is usually caused by the decrease in natural light. For this type of depression, the symptoms will go away with the arrival of the spring and summer months, and will habitually come back every year. Although bipolar disorder is a different disease than depression, it is traditionally classified within the same list because “someone with bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression” (National Institute of Mental Illness). However, bipolar disorder also causes an individual to experience tremendously “high- euphoric or irritable- moods”. These moods are known as “mania” or “hypomania” for the less extreme cases.

Again, just like with addiction, mental illnesses can be treated and oftentimes, cured. Recovery will be most effective when an individual seeks treatment early on in the disease, and they must continue to put forth a strong will throughout the entire process of their own recovery. Every individual being so distinctively different is what makes our world so unique, however it also makes figuring out diseases like these and treatments that work that much harder, because no one treatment will work the same for every individual. But thankfully with so many recent advancements in our technology and medical techniques, professionals have been able to come up with numerous different treatments for any and every individual. One of the treatment processes is known as psychotherapy. This is a process that treats mental illness through therapy performed by trained mental health professionals. “Psychotherapy explores thoughts, feelings, and behaviors, and seeks to improve an individual’s well-being” (Mental Health America). It is believed that the most effective way to encourage recovery is through a combination of psychotherapy and medication. Using medications is another way to promote recovery of an individual’s mental state. However, medication alone can not fully cure a mental illness. This route is used more so to lessen one’s symptoms. A support group can also be utilized to offer support to a group of people that struggle with a mental disorder. There is Complementary and Alternative Medicines that can be used as well, but these are not usually linked with the standard care methods. However, these can be used in replace of standard health practices or at the same time. In some of the severe cases, certain individuals many have to be hospitalized. This allows the patient to be monitored closely, be correctly diagnosed, and be in the presence of trained professionals that can alter their medications and dosages when and if it is needed. Some other options that can be explored are brain stimulation therapies, that are typically used when other treatments are not successful. One of the most common is the electroconvulsive therapy (ECT). This specific procedure requires the individual to be put under general anesthesia, and then small electric currents are sent through the brain. In doing this, it actually triggers a brief seizure on purpose. The main purpose of this particular treatment is to “cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions” (Mayo Clinic).

One of the largest debates is whether mental illnesses and substance abuse are connected. “The National Bureau of Economic Research (NBER) reports that there is a ‘definite connection between mental illness and the use of addictive substances’” (Dual Diagnosis.Org). It cannot be proven indefinitely that one of these diseases causes the other, but there are definite factors that “can contribute to the comorbidity between substance use disorders and mental illness” (National Institute on Drug Abuse). The first factor is the risk factors that lead to both substance abuse and mental illnesses. The two of these diseases have been proven to be caused by “overlapping factors such as genetic and epigenetic vulnerabilities, issues with similar areas of the brain, and environmental influences such as early exposure to stress or trauma” (National Institute on Drug Abuse). Another factor is the fact that “mental illnesses can contribute to drug use and addiction” (National Institute on Drug Abuse). This is because many individuals with a mental disorder tend to turn to drug use, to self-medicate. Lastly, it is said that drug use and addictions can lend a hand in the development of a mental illness. When drugs are used, it can alter some of the areas in the brain that certain mental disorders trigger as well. Continuing this use can cause a number of mental illnesses to fully emerge and take a toll on an individual’s physical and mental health. There have been multiple national surveys that have proven that about half of the individuals struggling with a mental illness at some point in their life, will battle a substance use disorder as well, and vice versa. In a community-based substance use disorder treatment program there is over 60 percent of adolescents that will meet the criteria for also having a mental illness. Today 38 percent of alcohol consumption, 44 percent of cocaine consumption, and 40 percent of cigarette consumption comes from patients suffering with a mental disorder. It is also believed that it is most common for drug use to start in adolescents, which is also when mental illness usually first appear.

In conclusion, both substance addictions and mental illnesses are equally as common, serious, and life-threatening. They both are unfortunately continuing to rise around the world and they are not being taken as serious as they should be. Everyone is entitled to their own opinions and while it is often believed that addiction and mental illness is all in your head, that has been scientifically proven to be incorrect. Both are very legitimate diseases and “even though everyone’s symptoms will be different, everyone matters and every single individual’s issues are just as valid as the next persons” (Christine Spencer). “An addiction and a mental illness is just as valid and serious as a cancer…all three are capable of ruining and often times ending lives” (Christine Spencer).

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Drug and Substance Abuse Essay

Introduction, physiology and psychology of addiction, prescription drug abuse, depressants, hallucinogens.

Drug and substance abuse is an issue that affects entirely all societies in the world. It has both social and economic consequences, which affect directly and indirectly our everyday live. Drug addiction is “a complex disorder characterized by compulsive drug use” (National Institute on Drug Abuse, 2010).

It sets in as one form a habit of taking a certain drug. Full-blown drug abuse comes with social problems such as violence, child abuse, homelessness and destruction of families (National Institute on Drug Abuse, 2010). To understand to the impact of drug abuse, one needs to explore the reasons why many get addicted and seem unable pull themselves out of this nightmare.

Many experts consider addiction as a disease as it affects a specific part of the brain; the limbic system commonly referred to as the pleasure center. This area, which experts argue to be primitive, is affected by various drug substances, which it gives a higher priority to other things. Peele (1998) argues that alcoholism is a disease that can only be cured from such a perspective (p. 60). Genetics are also seen as a factor in drug addiction even though it has never been exclusively proven.

Other experts view addiction as a state of mind rather than a physiological problem. The environment plays a major role in early stages of addiction. It introduces the agent, in this case the drug, to the abuser who knowingly or otherwise develops dependence to the substance. Environmental factors range from violence, stress to peer pressure.

Moreover, as an individual becomes completely dependent on a substance, any slight withdrawal is bound to be accompanied by symptoms such as pain, which is purely psychological. This is because the victim is under self-deception that survival without the substance in question is almost if not impossible. From his psychological vantage point, Isralowitz (2004) argues that freedom from addiction is achievable provided there is the “right type of guidance and counseling” (p.22).

A doctor as regulated by law usually administers prescription drugs. It may not be certain why many people abuse prescription drugs but the trend is ever increasing. Many people use prescription drugs as directed by a physician but others use purely for leisure. This kind of abuse eventually leads to addiction.

This problem is compounded by the ease of which one can access the drugs from pharmacies and even online. Many people with conditions requiring painkillers, especially the elderly, have a higher risk of getting addicted as their bodies become tolerant to the drugs. Adolescents usually use some prescription drugs and especially painkillers since they induce anxiety among other feelings as will be discussed below.

Stimulants are generally psychoactive drugs used medically to improve alertness, increase physical activity, and elevate blood pressure among other functions. This class of drugs acts by temporarily increasing mental activity resulting to increased awareness, changes in mood and apparently cause the user to have a relaxed feeling. Although their use is closely monitored, they still find their way on the streets and are usually abused.

Getting deeper into the biochemistry of different stimulants, each has a different metabolism in the body affecting different body organs in a specific way. One common thing about stimulants is that they affect the central nervous system in their mechanism. Examples of commonly used stimulants include; cocaine, caffeine, nicotine, amphetamines and cannabis. Cocaine, which has a tremendously high addictive potential, was in the past used as anesthetic and in treatment of depression before its profound effects were later discovered.

On the streets, cocaine is either injected intravenously or smoked. Within a few minutes of use, it stimulates the brain making the user feel euphoric, energetic and increases alertness. It has long-term effects such as seizures, heart attacks and stroke. Cocaine’s withdrawal symptoms range from anxiety, irritability to a strong craving for more cocaine.

Cannabis, also known as marijuana , is the most often abused drug familiar in almost every corner of the world, from the streets of New York to the most remote village in Africa. Although its addiction potential is lower as compared to that of cocaine, prolonged use of cannabis results to an immense craving for more.

It produces hallucinogenic effects, lack of body coordination, and causes a feeling of ecstasy. Long-term use is closely associated with schizophrenia, and other psychological conditions. From a medical perspective, cannabis is used as an analgesic, to stimulate hunger in patients, nausea ameliorator, and intraocular eye pressure reducer. Insomnia, lack of appetite, migraines, restlessness and irritability characterize withdrawal symptoms of cannabis.

Unlike stimulants, depressants reduce anxiety and the central nervous system activity. The most common depressants include barbiturates, benzodiazepines and ethyl alcohol. They are of great therapeutically value especially as tranquilizers or sedatives in reducing anxiety.

Depressants can be highly addictive since they seem to ease tension and bring relaxation. After using depressants for a long time, the body develops tolerance to the drugs. Moreover, body tolerance after continual use requires one use a higher dose to get the same effect. Clumsiness, confusion and a strong craving for the drug accompany gradual withdrawal. Sudden withdrawal causes respiratory complications and can even be fatal.

Narcotics have been used for ages for various ailments and as a pain reliever pain. They are also characterized by their ability to induce sleep and euphoria. Opium, for instance was used in ancient China as a pain reliever and treatment of dysentery and insomnia. Some narcotics such as morphine and codeine are derived from natural sources.

Others are structural analogs to morphine and these include heroin, oxymorphone among others. Narcotics are highly addictive resulting to their strict regulation by a majority of governments. Narcotics act as painkillers once they enter the body.

They are used legally in combination with other drugs as analgesics and antitussives but are abused due to their ability to induce a feeling of well being. Their addiction potential is exceptionally high due to the body’s tolerance after consistent use, forcing the user to use and crave for more to get satisfaction. Increase in respiration rate, diarrhea, anxiety, nausea and lack of appetite are symptoms common to narcotic withdrawal. Others include; running nose, stomach cramps, muscle pains and a strong craving for the drugs.

Hallucinogens affect a person’s thinking capacity causing illusions and behavioral changes especially in moods. They apparently cause someone to hear sounds and see images that do not exist. Lysergic acid diethylamide (LSD), which commonly abused hallucinogen, has a low addiction potential because it does not have withdrawal effects. They also affect a person’s sexual behavior and other body functions such as body temperature. There are no outright withdrawal symptoms for hallucinogens.

Isralowitz, R. (2004). Drug use: a reference handbook . Santa Barbara, Clif.: ABC-CLIO. Print.

National Institute on Drug Abuse. (2010). NIDA INfoFacts: Understanding Drug Abuse and Addiction . Web.

Peele, S. (1998). The meaning of Addiction : Compulsive Experience and its Interpretation . San Francisco: Jossey-Bass.

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• Common Hallucinogens and Dissociative Drugs
• Main Categories of Drugs and Its Mechanism of Action
• Hallucinogens, Inhalants and Prescription Drugs Effects
• The Psychology of Addiction and Addictive Behaviors
• Alcohol as the Most Common Depressant on Earth
• Prescription Painkillers, the New Drug Abuse of Choice
• Sedatives or Depressants in Individuals With a Mental Health Problem
• Using Depressants During Sleep Time
• The Role of CBT in Managing Severe Depressant Patients
• Post Incarceration Syndrome
• Psychoactive Drugs
• Adolescent’s Drug Abuse and Therapy Success
• Analysis of the Video “Effects of Alcoholism on Children: An Oral History Video”
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Essay on Drug/ Substance Abuse

Drug and substance abuse remains one of the most challenging and destructive problems facing societies worldwide. It refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. This essay aims to delve into the complexities of drug and substance abuse, examining its causes, effects, and the crucial steps needed to address this epidemic.

Drug and Substance Abuse

Drug and Substance Abuse involves the recurrent use of drugs or substances leading to significant impairment, including health problems, disability, and failure to meet responsibilities at work, school, or home. This includes the misuse of legal substances like alcohol and prescription medications, as well as illegal substances like heroin, cocaine, and methamphetamines.

Causes of Drug and Substance Abuse

The reasons behind drug and substance abuse are multifaceted and can vary from individual to individual:

• Genetic Predisposition : Research indicates a genetic component to the susceptibility to substance abuse.
• Mental Health Disorders : Many individuals with mental health disorders such as depression, anxiety, or PTSD turn to substances as a form of self-medication.
• Peer Pressure : Particularly among adolescents and young adults, peer pressure can significantly influence substance use.
• Stressful Life Events : Traumatic experiences, chronic stress, or life-changing events can lead to substance abuse as a coping mechanism.
• Curiosity and Experimentation : Often, particularly in young individuals, there’s a desire to experiment, which can lead to misuse and addiction.

Effects of Drug and Substance Abuse

Drug and substance abuse, a major public health challenge, affects individuals, families, and communities across the globe. This essay explores the multifaceted effects of drug and substance abuse, including physical health, mental well-being, social relationships, and broader societal impacts.

Physical Health Effects

Immediate physical effects.

• Altered State of Consciousness : Substances like alcohol, marijuana, and hallucinogens alter perception, mood, and consciousness.
• Overdose Risk : Excessive consumption of drugs can lead to overdose, potentially resulting in coma or death.
• Infectious Diseases : Intravenous drug use increases the risk of diseases like HIV and Hepatitis B and C due to needle sharing.

Long-Term Health Effects

• Organ Damage : Chronic substance abuse can lead to severe damage to vital organs like the liver (cirrhosis), heart, and brain.
• Neurological Impact : Long-term effects on the brain can include memory loss, cognitive decline, and mental health disorders.
• Physical Dependency : Prolonged use leads to dependency, where the body requires the substance to function normally.

Mental Health and Psychological Effects

• Mental Health Disorders : Substance abuse can trigger or exacerbate mental health conditions like depression, anxiety, and psychosis.
• Behavioral Changes : Changes in behavior, such as increased aggression or impulsivity, are common.
• Cognitive Impairments : Drugs can impair decision-making abilities, judgment, and other cognitive functions.

Social and Relationship Impacts

• Family Dynamics : Drug abuse can strain family relationships, leading to conflict, mistrust, and breakdown of family structures.
• Workplace Issues : It affects job performance, leading to decreased productivity, absenteeism, and higher risk of accidents.
• Legal Problems : Substance abuse can result in legal issues, including arrests for possession, driving under the influence, or engaging in illegal activities to support the addiction.

Societal and Economic Impacts

• Healthcare Costs : Treating drug-related health complications burdens healthcare systems.
• Crime and Safety : There’s a correlation between substance abuse and increased crime rates, impacting community safety.
• Economic Burden : The economic impact includes loss of productivity, healthcare expenses, and law enforcement costs.

Prevention and Treatment

• Education and Awareness : Programs aimed at educating individuals about the risks of drug use are crucial.
• Rehabilitation Programs : Effective treatment programs, including therapy and medication-assisted treatment, help individuals recover.
• Support Systems : Family, community, and peer support are vital in the recovery process.

Addressing Drug and Substance Abuse

• Prevention Programs : Education and awareness programs, particularly targeting young people, are crucial in preventing substance abuse.
• Treatment and Rehabilitation : Access to effective treatment, including counseling, medication, and support groups, is vital for recovery.
• Policy and Regulation : Government policies to regulate the availability of substances, and laws to address drug trafficking and misuse, play a critical role.
• Community Support : Community-based efforts, including support from families, schools, and religious organizations, are essential in supporting those affected.

The Role of Society and Individuals

• Destigmatization : Removing the stigma around substance abuse and addiction encourages individuals to seek help.
• Educational Initiatives : Schools and universities should have programs to educate students about the dangers of substance abuse.
• Role Models : Influential figures and celebrities should promote healthy lifestyles and speak out against substance abuse.
• Supportive Environment : Creating an environment that fosters open discussion and support for those struggling with substance abuse.

In conclusion, Drug and substance abuse is a complex issue requiring a multifaceted approach. It is not just a personal problem but a societal challenge that calls for comprehensive prevention strategies, effective treatment programs, supportive policies, and community involvement. Understanding and addressing the root causes, along with providing support and care for those affected, is crucial in mitigating the impact of this global issue. For students participating in essay competitions, exploring this topic provides an opportunity to contribute to a critical dialogue, advocating for change and supporting those in need.

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Co-occurring substance abuse and mental health problems among homeless persons: Suggestions for research and practice

Douglas l. polcin.

a Alcohol Research Group , Public Health Institute , USA

Communities throughout the U.S. are struggling to find solutions for serious and persistent homelessness. Alcohol and drug problems can be causes and consequences of homelessness, as well as co-occurring problems that complicate efforts to succeed in finding stable housing. Two prominent service models exist, one known as “Housing First” takes a harm reduction approach and the other known as the “linear” model typically supports a goal of abstinence from alcohol and drugs. Despite their popularity, the research supporting these models suffers from methodological problems and inconsistent findings. One purpose of this paper is to describe systematic reviews of the homelessness services literature, which illustrate weaknesses in research designs and inconsistent conclusions about the effectiveness of current models. Problems among some of the seminal studies on homelessness include poorly defined inclusion and exclusion criteria, inadequate measures of alcohol and drug use, unspecified or poorly implemented comparison conditions, and lack of procedures documenting adherence to service models. Several recent papers have suggested broader based approaches for homeless services that integrate alternatives and respond better to consumer needs. Practical considerations for implementing a broader system of services are described and peer-managed recovery homes are presented as examples of services that address some of the gaps in current approaches. Three issues are identified that need more attention from researchers: (1) improving upon the methodological limitations in current studies, (2) assessing the impact of broader based, integrated services on outcome, and (3) assessing approaches to the service needs of homeless persons involved in the criminal justice system.

Homelessness in the U.S. has been a significant problem for decades and communities have struggled to find solutions. On any given night in 2013, over 600,000 persons in the U.S. were homeless ( National Alliance to End Homelessness, 2014 ). The public health implications of homelessness are significant and include syndemic interactions that exacerbate substance abuse, health problems, HIV risk, and mental health symptoms ( Fitzpatrick-Lewis et al ., 2011 ; Kertesz, Crouch, Milby, Cusimano, & Schumacher, 2009 ; Larimer et al ., 2009 ). Mortality rates among homeless persons are more than three times that of persons with some type of housing ( O'Connell, 2005 ).

Homelessness is associated with increased risk to be involved in the criminal justice system. A variety of papers document high rates of homelessness for offenders leaving state prisons ( Petersilia, 2003 ) and local jails ( Freudenberg, Daniels, Crum, Perkins, & Richie, 2005 ; Petteruti & Walsh, 2008 ). Once they are homeless, these individuals are at increased risk to reengage in illegal activities that result in re-incarceration ( Greenberg & Rosenheck, 2008 ). Lack of stable housing also leaves individuals vulnerable to being victims of crime such as physical and sexual assault ( Gaetz, 2006 ).

There have been increases in funding for homeless services in recent years and it appears to be having a beneficial effect ( National Alliance to End Homelessness, 2014 ). Between 2012 and 2013, overall homelessness in the U.S. decreased by 3.7%, although there was significant variation among individual states. Funding has increased for a variety of housing programs, including emergency shelters, permanent housing, and specialized Veteran's Administration programs. As funding increases, service providers, researchers, and local governments debate about what types of services to increase.

Although studies vary, research consistently shows over a third of individuals who are homeless experience alcohol and drug problems (e.g., Gillis, Dickerson, & Hanson, 2010 ) and up to two-thirds have a lifetime history of an alcohol or drug disorder ( Robertson, Zlotnick, & Westerfelt, 1997 ). The relationship between homelessness and substance abuse is complex, with studies suggesting that substance use can be both a cause and consequence of homelessness ( National Coalition for the Homeless, 2009 ). Until recently, few services addressed the needs of substance abusing homeless persons who were not motivated to address their substance use. In addition, even when homeless individuals were motivated to address substance abuse problems, access to the variety of services needed were lacking. Notably lacking has been successful integration of substance abuse treatment, permanent stable housing, and related services such as mental health.

This paper begins with a brief description of two approaches addressing co-occurring substance abuse and homelessness, Housing First and linear. Next, we highlight how reviews of the homeless services literature have reached mixed and inconsistent conclusions about the effects of services for this population and we point out a variety of methodological weaknesses that limit the confidence of research findings. The paper then describes several recent papers calling for broader based, flexible, and integrated service delivery to homeless persons (e.g., Corporation for Supportive Housing & National Council for Behavioral Health, 2014 ; Paquette & Winn, 2015 ). We add to this literature by suggesting that peer-managed alcohol and drug recovery homes could play a greater role in the mix of services offered to homeless persons, particularly those who are motivated to pursue abstinence and have some period of stability in the community. Practical considerations for improved service integration are presented along with suggestions for research that can strengthen the empirical base for integrated, broader based services.

Models for assisting homeless individuals with substance abuse

Two prominent models have emerged in response to the need for housing for persons with co-occurring substance abuse and unstable housing: linear and Housing First. The linear approach ( Kertesz et al ., 2009 ; Ridgway & Zipple, 1990 ) emphasizes abstinence from substances as an explicit goal. Substance abuse treatment is an integral first step to eventually obtaining permanent stable housing. Thus, stable housing is an end goal. In contrast, Housing First takes the view that provision of subsidized and in some cases free housing should occur first ( Tsemberis, Gulcur, & Nakae, 2004 ). While case management services are sometimes offered to residents, Housing First emphasizes a “low threshold” with personal choice about whether to address substance abuse and mental health problems. Housing First programs provide permanent housing largely without conditions, either in decentralized apartments or larger, congregant facilities. The accepting tone of this approach may be particularly helpful to persons who are chronically homeless (longer than one year) and persons with chronic psychiatric conditions such as schizophrenia ( Padgett, Gulcur, & Tsemberis, 2006 ). In addition, the Housing First approach serves as an alternative to formal treatment for persons who have had negative experiences.

Research on Housing First

A variety of studies support both Housing First and linear models. Kertesz et al . (2009) reviewed outcomes for both models and concluded they evidenced different strengths. When individuals with mental health and substance abuse problems enter Housing First programs and are provided subsidized or free housing without requirements, such as completing treatment or abstinence from drugs, retention is excellent (e.g., Collins, Malone, & Clifasefi, 2013 ; Tsemberis et al ., 2004 ). However, findings for other outcomes are mixed or not well studied, particularly substance abuse problems. For example, some studies reporting favorable outcomes (e.g., Padgett et al ., 2006 ; Padgett, Stanhope, Henwood, & Stefancic, 2011 ) did not assess important measures of drinking, such as days of heavy drinking and drinking-related problems. The definition of heavy drugs in these studies was a very low threshold: any drug use four or more times over a six-month assessment period. In the Home Chez Soi study of Housing First in Canada, Kirst, Zerger, Misir, Hwang, and Stergiopoulos (2015) used two individual items from the Addiction Severity Index (ASI) Alcohol Scale to assess alcohol outcome rather than the ASI scaled scores. No rationale was provided. Another example of questionable measures among Housing First studies was the use of a dichotomous measure of treatment attendance to assess the effect of treatment on outcome. Attendance was defined as any treatment during the last month (even a single session) versus no treatment (e.g., Collins, Malone, & Larimer, 2012 ).

There have also been concerns about inclusion and exclusion criteria. Some studies did not specify substance abuse inclusion criteria that would ensure substance abuse problems existed among the residents at the time they entered the study (e.g., Tsemberis et al ., 2004 ). In this scenario, no differences in substance abuse outcomes between study conditions might be the result of limited room for improvement among individuals in both groups rather than equivalent effectiveness of interventions. A different type of problem is the use of a single group design of participants who entered Housing First with high rates of alcohol problems. Here, the improvements noted over time could be due to regression to the mean or ceiling effects (e.g., Collins, Malone, Clifasefi, et al. , 2012 ). Finally, Kertesz et al . (2009) questioned the appropriateness of some of the “usual care” comparison conditions, many of which were unspecified aggregate conditions, limited by underfunding, and lacking evidence-based interventions. In recent analyses of data from the Home Chez Soi study (e.g., Kirst et al ., 2015 ; Stergiopoulos et al ., 2015 ), there was very little information about the treatment as usual (TAU) condition, including services received or offered. Especially important, there is nothing about the availability of housing for the TAU group. We do know the Housing First condition received subsidized and in some cases free housing. The potential effects of offering subsidized housing as part of the TAU condition were unknown.

Research on linear approaches

While formal substance abuse treatment programs that are part of the linear approach to homelessness have been studied for many years and have demonstrated consistent albeit moderate effectiveness (National Institute on Drug Abuse, 2012), there have been serious problems with retention. A majority of persons in formal treatment programs do not complete treatment ( Ball, Caroll, Canning-Ball, & Rounsaville, 2006 ; Palmer, Murphy, Piselli, & Ball, 2009 ). Tsemberis et al . (2004) suggested many homeless individuals, particularly those with significant mental health disorders, are unwilling or unable to comply with linear model requirements such as engaging in treatment and maintaining abstinence from drugs and alcohol. Relative to Housing First, most studies have shown the linear models yield significantly lower retention rates ( Kertesz et al ., 2009 ).

An area of strength in linear housing models is they have been shown to have favorable substance abuse outcomes. For example, using a state-of-the-art, abstinent contingent housing and treatment approach known as the Birmingham model, Milby, Schumacher, Wallace, Freedman, and Vuchinich (2005) showed that abstinent contingent housing had better cocaine outcomes than non-abstinent contingent housing. The review of homeless studies by Hwang, Tolomiczenko, Kouyoumdjian, and Garner (2005) concluded that a variety of substance abuse and mental health interventions can help homeless individuals, but specific types of interventions do not show superior efficacy. However, a serious problem for linear programs is they often lack stable, permanent housing options for individuals who complete treatment even though the model calls for provision of permanent housing as part of the continuum or care. Even when individuals in linear service models achieve abstinence, they are vulnerable to relapse and reoccurrence of homelessness if they are not able to find permanent housing ( Kertesz et al ., 2009 ).

Systematic reviews of homeless services studies

Systematic reviews of the homeless services literature have reached inconsistent conclusions. For example, Rog et al . (2014) assessed studies of permanent supportive housing for homeless persons with mental illness and substance abuse and concluded permanent supportive housing was associated with reduced homelessness, increased housing tenure, and deceased hospitalizations. Compared to other housing models (e.g., those requiring abstinence or engagement in treatment), consumer satisfaction among residents in permanent supportive housing was higher. However, Hwang et al . (2005) concluded that studies assessing the independent effect of subsidized housing alone on substance abuse, physical health, and mental health were inconsistent. Their conclusions suggested that provision of case management to homeless persons with substance abuse problems was important regardless of whether supportive housing was provided. A good example of combined Housing First and intensive case management or Assertive Community Treatment is the Home Chez Soi study in Canada ( Kirst et al ., 2015 ; Polvere, Macnaughton, & Piat, 2013 ; Stergiopoulos et al ., 2015 ). Fitzpatrick-Lewis et al . (2011) reviewed 84 studies on the effectiveness of housing services for homeless people with substance abuse issues or other concurrent disorders (e.g., mental illness). They indicated provision of housing was associated with increased housing tenure and decreased substance use, relapse, and health services utilization. However, they also concluded that abstinent dependent housing was more effective in achieving abstinence than non-abstinence dependent housing or no housing.

Permanent housing services, such as Housing First, have been identified as “best practices” by the Substance Abuse and Mental Health Service Administration, the U.S. Department of Housing & Urban Development, and the U.S. Conference of Mayors ( Corporation for Supportive Housing & National Council for Behavioral Health, 2014 ; Kertesz et al ., 2009 ). Although Housing First has enjoyed widespread popularity, a recent review by Waegemakers Schiff and Schiff (2014) concluded political support was more the basis for popularity than scientific evidence that met best practices criteria. Of particular note is the fact that 11 of the 18 studies reviewed used data from one site in New York City (Pathways to Housing). In addition, many studies had inadequate procedures for selecting appropriate participants and lacked measures to assess services delivered. The authors concluded there were favorable results for Housing First studies overall, but methodological problems resulted in weak reliability and generalizability.

Considerations for research

Taken together, systematic reviews show some degree of support for Housing First and linear approaches, but they also clearly illustrate the need for more research before we can make definitive conclusions. There is a need for research procedures and measures that are more rigorous. For example, confidence in research findings would be improved with more consistent use of standardized assessment instruments to assess substance use, mental health problems, and services received. In particular, inspection of clinical records to determine current or past substance use and mental health disorders, which has been used in some of these studies, is methodologically weak. When the term dual diagnosis is used, we need to be clear about disorders that were included and excluded as well as their severity.

There is also a need for studies to better clarify intervention and comparison conditions. When a term such as “usual care” is used it needs to be specified. What services are included in usual care? How accessible are the services? What services do participants actually receive? For example, Kertesz et al . (2009) noted that linear models of care are designed to provide permanent housing arrangements after individuals comply with treatment and abstinence requirements. However, treatment providers do not typically control housing subsidies and therefore treatment does not always lead to housing, even when the treatment is effective. Rog et al . (2014) addressed the lack of clarity about services received in terms of fidelity. Although they focused primarily on inadequate fidelity for assessing adherence to permanent housing models, fidelity problems are arguably worse in terms of measuring fidelity to comparison conditions.

Although most of the literature reviews on homeless services call for more studies using randomized designs, there are potential downsides to this approach. In a paper on residential recovery homes for persons with alcohol and drug disorders, Polcin (in press) pointed out that randomization eliminates self-determination of services received. The process of selecting a recovery home and being offered admission by a program sets the stage for subsequent recovery experiences. Because consumer choice and empowerment about receipt of housing and other services is central to the Housing First model there are concerns about generalization of results when using randomized designs. In addition, the sample of persons who are willing to be randomized to where they live for months or even years may be different from self-selected samples one individuals choosing to enter housing conditions.

An alternative to randomized designs is to use pre–post naturalistic designs where outcomes between groups of individuals receiving different service models are compared over time. Although naturalistic designs cannot be used to show causality, they have the advantage of mirroring real world conditions and that increases generalization of study findings. In addition, there are ways to strengthen these designs to increase confidence about their effects. Examples include the use of multivariate models that parse out the relative effects of influential variables that can confound intervention effects, matching designs that compare outcomes for similar individuals in intervention and comparison conditions, and propensity score matching, which controls for covariates that predict receiving an intervention versus not receiving it ( Polcin, in press ).

A final issue that needs more attention is how community stakeholders experience homeless services. If housing models are to expand and meet the current need for housing among the homeless, there will need to be significant political and popular support. Not in my back yard (NIMBY) has been the term used to describe opposition to housing and other services in community settings. Lee, Tyler, and Wright (2010) noted that federal initiatives to address homelessness have been offset to some extent at the local level by NIMBY resistance to housing services in suburban areas and by the enactment of “quality of life” ordinances that criminalize homeless people's basic survival behaviors. However, relatively few papers addressing homeless services have addressed strategies to overcome NIMBY resistances. For example, where possible, it would be helpful to document community support for homeless services as well as understand resistances in more detail. Studies of stakeholder views about abstinence-based recovery homes for persons with substance use disorders have shown strong neighborhood support as well as support from local government (e.g., Jason, Roberts, & Olson, 2005 ; Polcin, Henderson, Trocki, Evans, & Wittman, 2012 ). Resistances to recovery homes tended to come from persons unfamiliar with them. Among a number of strategies suggested was more interaction between recovery home residents and stakeholder groups. However, it is unclear to what extent these findings and suggestions can generalize to homeless services, particularly centralized Housing First programs where service providers view substance use as a personal choice. Among neighbors of recovery houses there was strong support for the requirement that residents remain abstinent from drugs and alcohol ( Polcin et al ., 2012 ).

Integrated service delivery

Gillis et al. (2010) suggested there is enormous heterogeneity among homeless persons' needs and preferences. For example, Polvere et al . (2013) found most persons enrolled the Housing First condition in the Home Chez Soi study had positive experience, but a subgroup felt socially isolated in the decentralized apartments. Homeless persons also vary by needs, which can range from mild to severe mental health, medical, and substance abuse problems. They also can vary in terms of risk for HIV infection and involvement in the criminal justice system. Moreover, there is heterogeneity in the level of motivation to address these problems. Some homeless persons recognize their problems and are receptive to services that might be helpful. Others are unaware or want to deal with problems on their own.

The heterogeneous characteristics of homeless persons support the use of a flexible, multidimensional approach to service delivery rather than one focusing on a single model ( Corporation for Supportive Housing & National Council for Behavioral Health, 2014 ; Paquette & Winn, 2015 ). For example, for homeless persons with co-occurring substance abuse who have no desire to quit using substances and no criminal justice mandate requiring treatment Housing First might be the best approach. There may be few other options for them. Because these individuals frequently present service needs for substance abuse, mental health, and other problems, Housing First approaches that provide on-site case management that can connect them with the types of services they need is important (e.g., Stergiopoulos et al ., 2015 ).

Homeless individuals who are motivated to address their substance abuse issues should typically be referred to a treatment program because research shows treatment is effective for many individuals, including those who are homeless ( Hwang et al ., 2005 ; National Institute on Drug Abuse, 2012). However, seriously lacking in many linear approaches is the permanent housing service after completion of treatment. As Kertesz et al . (2009) noted, treatment providers do not typically control housing subsidies and therefore treatment does not always lead to housing, even when the treatment is effective. Therefore, an issue that providers should consider when determining referrals for homeless persons with substance abuse problems is the availability of permanent housing after treatment is completed.

Although there is currently widespread support for resident centered approaches that emphasize consumer readiness and choice (e.g., Tsemberis et al ., 2004 ), we need to recognize that some homeless persons are mandated to receive treatment by the criminal justice system. Typically, criminal justice systems require abstinence among offenders with alcohol or drug problems and therefore refer these individuals to abstinence-based treatment programs. For them, motivation is often based on a desire to avoid incarceration rather than to address alcohol or drug use. This does not necessarily bode poorly for treatment outcome. Among the larger population of substance abusers, those coerced into treatment through the criminal justice system have fared as well as those entering voluntarily (National Institute on Drug Abuse, 2012).

Despite their criminal justice status, persons coerced into treatment or abstinent contingent housing through the criminal justice system have some degree of choice. First, they can opt for criminal justice sanctions rather than enter treatment. Second, they often have choices about programs to which they can apply. Finally, the programs are typically not obligated to accept individuals, which results in some degree of mutual selection. The limitation of Housing First for these individuals is that the criminal justice system typically mandates abstinence, which is inconsistent with the Housing First approach.

Korcha and Polcin (2012) pointed out there is a need for more research targeting outcomes for the growing numbers of individuals being released from incarceration, particularly in California where large numbers of ex-offenders are reentering communities. They suggested that peer-managed recovery homes, which are described in detail below, may be good options for many of these individuals. Because they do not mandate abstinence, Housing First services typically receive fewer referrals from the criminal justice system. Although few studies have addressed Housing First approaches for criminal justice offenders, one study did assess outcomes for Housing First residents with a history of misdemeanor crimes. Individuals in the sample apparently did not have a criminal justice mandate requiring services (i.e., Clifasefi, Malone, & Collins, 2013 ). Consistent with a variety of studies in the substance abuse field, the single group design showed that longer retention in the program resulted in better criminal justice outcomes. It would be interesting to assess outcomes of criminal justice referrals to Housing First without a mandate for abstinence, if a criminal justice jurisdiction would be willing to agree to such a condition.

Residential recovery homes for homeless persons

Overlooked in most of the current debates about services for homeless persons with co-occurring substance abuse is the potential role of residential recovery homes. These facilities serve a variety of persons with substance abuse disorders and represent a range of settings, some of which are unstructured and peer managed and others that are managed by professionals who provide on-site services ( National Association of Recovery Services, 2012 ). Most recovery homes emphasize a “social model” philosophy of recovery that emphasizes peer support for abstinence and involvement in 12-step recovery programs ( Polcin, Mericle, Howell, Sheridan, & Christensen, 2014 ). However, Mericle, Miles, Cacciola, and Howell (2014) noted that some recovery homes in Philadelphia included a variety of on-site services (e.g., counseling and medical care) in addition to peer support. Recent papers specifically targeting housing for the homeless (e.g., Corporation for Supportive Housing & National Council for Behavioral Health, 2014 ; Paquette & Winn, 2015 ) have supported an enhanced role for recovery residences. However, they are not appropriate for all homeless persons. Particularly contraindicated are individuals who do not wish to abstain from substances and those with severe and persistent mental illness. Nevertheless, Paquette and Winn (2015) suggested that including recovery homes in the mix of potential housing services is a positive response to calls for increased consumer choice in selection of services.

Recovery homes that offer a relatively higher degree of structure and on-site services, such as some of the houses described by Mericle et al . (2014) in Philadelphia, can be entry points for some persons into homeless service systems, particularly those who are motivated to live in an alcohol- and drug-free environment. However, one of the pitfalls of some of these facilities is that they offer time-limited lengths of stay and lack provision of permanent housing once residents reach the maximum length of time in the residence.

Peer-managed recovery homes

Expansion of two types of peer-managed recovery homes could help address the need for permanent sober housing: California Sober Living Houses (SLHs) ( Polcin, 2009 ; Polcin & Henderson, 2008 ) and Oxford Houses ( Jason, Olson, & Foli, 2008 ). Peer-managed recovery homes are resources for persons who have established some stability in the community and who are motivated to maintain an abstinence-based lifestyle. The individuals who enter these homes are typically not chronically homeless (longer than one year) or persons with chronic and severe mental illness (e.g., schizophrenia and other persistent psychotic disorders). The reason for this is that peer-managed homes require a level of autonomy and stability that is not often characteristic of individuals who are chronically homeless or suffering from severe mental illness. However, this does not mean that housing and psychiatric problems are not prevalent issues. In studies of SLHs, only 36% of the entering residents indicate they have stable housing at the time they enter ( Polcin, Korcha, Bond, & Galloway, 2010a ; Polcin, Korcha, Bond, & Galloway, 2010b ). In one study of an urban SLH program over a third (35%) indicated homeless or shelter was their typical living situation the past six months ( Polcin et al ., 2010a ). In a different sober living program, a majority (52%) indicated they were marginally or temporarily housed, examples of which included staying with friends or leaving incarceration with no stable place to stay ( Polcin et al ., 2010b ). Majer, Jason, Ferrari, and North (2002 ) studied Oxford Houses in St. Louis and reported that half had a history of homelessness. Similarly, psychiatric symptoms are issues in peer-managed recovery homes even though there were few persons with chronic, severe disorders such as schizophrenia. For example, Polcin, Korcha, and Bond (2015) found the average level of psychiatric severity in a sample of 245 SLH residents was similar to that of persons attending outpatient treatment for mental health symptoms.

Although peer-managed recovery homes do not offer formal services on-site, residents are free to pursue whatever professional services they need in the community and most homes encourage or require residents to be involved in 12-step recovery groups such as Alcoholics Anonymous. Some SLHs are targeted as “step down” homes where individuals can live after they complete a residential treatment program. In addition, some outpatient treatment programs have opened SLHs as alcohol- and drug-free living arrangements for individuals enrolled in outpatient treatment. However, most California SLHs and all Oxford Houses are freestanding facilities not associated with formal treatment.

Unlike formal treatment or Housing First approaches, the residents themselves typically pay most of the costs through earned income, family resources, or government subsidies, such as general assistance or social disability insurance. Because residents share living arrangements, the rental costs per person tend to be affordable. However, persons with no stable income, family support, or government subsidy may not be able to meet their financial obligations. As long as residents are able to meet financial obligations and comply with house expectations (e.g., abstinence), they can remain as long as they like. Relapse typically results in the resident leaving the home for some minimal period of time, but they typically can reenter if assessed as motivated to reestablish abstinence. Learning from relapses is viewed as an important part of recovery. Thus, these settings offer the potential for long-term and even permanent housing with very little cost to state and local governments.

Studies of sober living and Oxford Houses have revealed favorable longitudinal outcomes on measures of alcohol, drug, employment, and legal problems ( Jason et al ., 2008 ; Polcin et al ., 2010a , 2010b ). These studies used established, psychometrically sound instruments, such as the ASI (McLellan et al ., 1992), the Brief Symptom Inventory (Derogatis & Melisaratos, 1983), and the Diagnostic Interview Schedule ( Robbins, Cottler, & Keating, 1989 ). To enhance generalization of study findings, few inclusion/exclusion criteria were used.

None of the sober living and Oxford House studies specifically targeted recruitment of homeless persons. However, research on broad samples of residents that included significant numbers of persons with a history of homeless has yielded favorable outcomes. For example, in a study of 53 residents of Oxford Houses in St. Louis, half of the sample had a history of homelessness ( Majer et al ., 2002 ). Six-month outcomes showed 42% continued to reside in the houses and 27% left the houses on good term. In a study of 55 residents in SLHs in California over one-third indicated their primary living situation during the past six months was homeless or living in a shelter and another 16% indicated their primary housing was criminal justice incarceration ( Polcin et al ., 2010a ). Six months after entry into the SLHs, residents showed significant improvement in terms of substance use, arrests, and employment. Importantly, these improvements were maintained at 18 months even though most residents had left the homes by that point.

Integration of peer-managed recovery homes into broad based services

Peer-managed recovery homes such as California SLHs and Oxford Houses have the potential to play unique roles within linear and Housing First models. Within linear models, they can be housing resources for previously homeless persons completing residential treatment or places for them to reside while they attend outpatient programs ( Polcin et al ., 2010a ). Kertesz et al . (2009) pointed out that the lack of permanent housing is a common gap in linear systems of care. Peer-managed recovery homes have the potential to fill that gap because residents are free to stay as long as they wish. Because recovery homes require alcohol and drug abstinence and encourage or mandate attendance at 12-step groups, they provide an approach that is consistent with most treatment programs. In this way, recovery homes emphasize concepts and practices that are familiar to residents and reinforcing of their treatment experiences. For individuals who found treatment to be helpful, this consistency adds to the therapeutic value.

Peer-managed homes can also compliment Housing First approaches to homelessness. For example, once stabilized in a Housing First apartment some individuals may decide at some point to quit their substance use. However, if they reside in an environment that tolerates substance use, pursuing that goal might be difficult. Living in a recovery home environment might be a much more effective way of responding to the individual's needs at that point and therefore should be available. Conversely, when individuals in recovery homes are not able or willing to comply with requirements for abstinence Housing First should be a readily available alternative to homelessness. In this manner there would be a cross referral process based on resident needs rather than competition between the two approaches.

One of the obstacles to peer-managed recovery homes is cost. Currently, most individuals in Oxford Houses and California SLHs pay rent using earned income or family resources. In a limited number of cases, the criminal justice system will pay for several months of rent but subsequently will expect the resident to pay costs. In low-income urban areas, some residents are able to pay costs using social security disability or general assistance. However, these homes are often not ideal because to make them affordable the homes serve a large numbers of residents per square footage and multiple residents share bedrooms. There is no clear rationale why one type of permanent housing is subsidized by government funding (Housing First) and one is not (recovery homes). Ensuring the availability and affordability of peer-managed recovery homes within Housing First and linear models of care would contribute important services currently lacking: permanent, abstinent-based housing that draws primarily on peer support as the active ingredient for successful recovery.

Researchers and practitioners frequently debate about the most appropriate service models for homeless persons with co-occurring substance abuse. However, a variety of weaknesses in the methods that have been used to study homeless services suggests caution when pointing to empirical research supporting different models. To improve the evidence base for systems of care for homeless persons with substance use disorders there needs to be closer attention to measurement of the characteristics of homeless persons, specification of inclusion and exclusion criteria that help focus studies on specific problems, and assessment of the types of services participants receive within different models. Although randomized designs have the advantage of showing causality, they can entail problems with generalization to the real world conditions of homeless persons, such as the typical ways they access services. This paper urges researchers to consider a wide array of research designs to address different aspects of homeless services.

Although several recent papers (e.g., Corporation for Supportive Housing & National Council for Behavioral Health, 2014 ; Paquette & Winn, 2015 ) have called for broader based service delivery systems that integrate Housing First and linear models, little has been done to integrate these models in community practice. This paper has described ways these two models complement each other and ways that practitioners could implement broader based, integrated approaches that respond better to individual needs. Homeless persons often move through different periods of motivation ranging from a desire to receive help to address their problems to simply receiving help for basic needs such as food and shelter. Current service systems for the homeless have not been sufficiently flexible to respond to these changes.

Currently, when criminal justice offenders are leaving incarceration and have a mandate to receive services, they typically are referred to programs that require abstinence from alcohol and drugs. This procedure is understandable given the consistent association between substance use and crime and relatively favorable outcomes for offenders in abstinence-based treatment programs. However, peer-based recovery homes could play stronger roles in providing long-term abstinent housing as part of the endpoints for linear-based service systems. Although the Housing First principle of supporting abstinence as one option for residents is not generally consistent with criminal justice requirements mandating abstinence for all ex-offenders, it would be interesting to assess illegal activities and arrests among Housing First residents without mandated abstinence.

Absent in most of the debates about services for homeless persons with co-occurring substance abuse is the potential role of peer-managed recovery homes, such as California SLHs and Oxford Houses. Most of these facilities require a level of functional and financial independence that is frequently lacking among persons who are chronically homeless or suffering from severe mental illness. However, they have the potential to fill existing service gaps for both Housing First and linear models. Within Housing First models, they can be an important referral resource when residents receiving permanent housing subsidies decide they wish to attempt abstinence. Many Housing First environments are not suitable for persons attempting abstinence because they allow substance use among residents and are unlikely to have the social support often necessary to support abstinence. In linear service systems, peer-managed recovery homes can provide permanent housing after inpatient treatment, during concurrent outpatient care, or after residence in a more structured, professionally staffed recovery home. The potential impact of peer-managed recovery homes on linear service systems is high because lack of permanent, affordable housing that maintains the gains made in treatment has been a serious and widespread problem within linear systems.

Disclaimer statements

Contributors Dr. Polcin is the sole author of this paper.

Funding National Institutes of Health.

Conflicts of interest No conflicts of interest.

Ethics approval No data were collected for this paper. Ethical approval not required.

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The Relationships between Mental Health and Substance Abuse Treatment and Juvenile Crime

The purpose of this paper is to examine the effectiveness of mental health and substance abuse treatment in reducing crimes committed by juveniles. The observed high correlations between crime, substance abuse and poor mental health suggests that factors which reduce substance abuse and improve mental health may also be effective in reducing criminal activities. This paper uses detention data in conjunction with substance abuse and mental health treatment data for youth enrolled in the Colorado state foster care program. We analyze the impact of treatment in delaying or preventing this group of at-risk youth from engaging in criminal behavior. Results show a negative effect, i.e., longer duration before detention, for youth who receive treatment and for youth in areas with high treatment rates.

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New Research Will Provide Insights into the Behavioral Health Workforce and the Services They Provide

AcademyHealth is highlighting four new projects at the UNC Behavioral Health Workforce Research Center to address the strategic aims of the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Behavioral health practitioners play an increasingly important role within the U.S. health care workforce as the incidence of mental health and substance use disorders (SUD) continue to rise nationally. Recent data from the Substance Abuse and Mental Health Services Administration (SAMHSA) reveal that in 2022, almost a quarter of all US adults (23.1 percent) reported having a mental illness in the past year, while 17.3 percent of people aged 12 or older reported having a substance use disorder in the same timeframe. Despite the increase in need for behavioral health services, individuals continue to face many different barriers in accessing the care they need, such as cost, insurance coverage, and provider availability. 

It is critical that state and federal policymakers have a full, nuanced understanding of the behavioral health practitioner workforce as it seeks to meet the growing need for care. With funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) the University of North Carolina at Chapel Hill Behavioral Health Workforce Research Center ( UNC-BHWRC ) undertook 10 projects in 2023 that address national-level planning and policy-relevant research questions. Now, in the second year of this effort, UNC-BHWRC will focus on an additional eight projects whose findings on the behavioral health workforce will inform SAMHSA and HRSA’s strategic aims. AcademyHealth is supporting the dissemination of UNC-BHWRC’s findings to the health services research community for the following projects:

Understanding the Continuum of Behavioral Health Professionals Working in Substance Use and Addiction Services in the United States

Within the behavioral health workforce, there exists a broad range of professionals known as addiction counselors. These professionals vary widely in terms of their training, education, certification, licensure requirements, and reimbursement allowances, all of which have the potential to differ widely from state to state. To better understand the diversity within this workforce and between states, this UNC-BHWRC project aims to determine how addiction counselors are identified within each state and describe the proportion of states that permit addiction counselors and other behavioral health professionals to be reimbursed for substance use treatment and service delivery. Identifying these differences across states and programs will provide important details and context for policymakers looking to improve their states’ behavioral health services.

Inclusion of Perinatal Services at Mental Health and Substance Use Treatment Facilities in the U.S.

An estimated one in five pregnant-capable people will experience a behavioral health disorder during the perinatal period (during pregnancy and the postpartum period of up to 12 months after delivery). Furthermore, the risk of developing SUD is highest for birthing people aged 18 to 29 years old, increasing throughout the reproductive years, and co-occurring SUDs are common among those with any SUD in pregnancy. Left untreated, these behavioral health disorders worsen maternal mortality rates and increase the likelihood of poor outcomes for both baby and birth parent. 

Recent efforts at the federal and state level emphasize the importance of increasing access to behavioral health treatment for pregnant and post-partum individuals. This UNC-BHWRC project will use the National Substance Use and Mental Health Services Survey (N-SUMHSS) to understand the inclusion of perinatal service delivery at mental health and substance use treatment facilities in the U.S. The information gleaned from this project will help inform current efforts to strengthen parental health and behavioral health systems. 

Educational Pathways to Professional-level Behavioral Health Degree Programs

Many individuals in need of behavioral health services are unable to access this care, particularly those in rural areas and those from communities of color . Researchers and policymakers broadly agree that bolstering the behavioral health workforce is necessary to alleviate these disparities in care access, particularly in areas identified as mental health care professional shortage areas. There is also broad acknowledgement that increasing diversity within the behavioral health workforce can improve the delivery of culturally and linguistically appropriate services. 

In support of the goal to increase supply, geographic distribution, and diversity of the behavioral health workforce, this UNC-BHWRC’s project will identify common pathways for individuals to enter full-time behavioral health professions in the U.S. This study will leverage nationally representative data to identify distinct educational pathways into graduate-level behavioral health professions and assess associations between particular pathways and individual and employment characteristics.

Advanced Behavioral Health Training in Geriatric Fellowships

Researchers estimate that the number of Americans aged 65 years and older will reach 80 million in 2040, one in five Americans. As this population increases, so will the number of individuals in need of behavioral health services. Indeed, SAMHSA notes that 15 percent of older adults are impacted by behavioral health problems; if this statistic holds true, roughly 12 million older adults will be impacted by behavioral health problems in 2040.

There are unique factors to consider when responding to the needs of older adults with behavioral health needs, such as the loss of friends, relationships, jobs, and identity that occur with age, acute and chronic physical health conditions that are common among older adults, and the growing diversity of the older adult population. As such, geriatric fellowships may be an opportunity to advance behavioral health training for physicians who provide this care to older adults, thus increasing access to behavioral health care. In this project, UNC-BHWRC will explore the distribution of geriatric fellowships by physician specialty (family medicine, internal medicine, and psychiatry) using data from the Accreditation Council for Graduate Medical Education (ACGME) and surveying geriatric fellowship program directors. 

Together with SAMHSA and HRSA, AcademyHealth will support the researchers at UNC-BHWRC as they conduct their studies and share findings as soon as they are available. Information about the UNC-BHWRC and previous studies is available here .

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Mental Health and Substance Use Disorders Often Go Untreated for Parents on Medicaid

By Emily Baumgaertner

For parents struggling with mental health or substance use disorders, access to treatment can often mean the difference between keeping and losing their children. But a new analysis of health and child welfare records found that a significant portion of those who were eligible for Medicaid coverage for such treatment were not getting it.

The analysis, published Friday by researchers at the nonprofit institute RTI International and the Department of Health and Human Services, found that fewer than half of parents on Medicaid who had substance use disorders and had been referred to authorities over suspicions of child abuse or neglect had received treatment.

Some Context: Experts say bad situations can often be reversed with treatment.

Both mental health and drug addiction crises have been roiling the country, and the effects of parental drug use and mental illness can quickly trickle down to their children . Public health experts say substance use disorders can incapacitate a previously diligent parent and lead to the involvement of child protective services.

In 2021 alone, more than seven million children were referred to authorities over worries of maltreatment, according to a federal report , and more than 200,000 were removed from their homes. But research shows that when parents seek treatment for psychiatric and substance use disorders , they are far less likely to experience family separation.

The Numbers: What the researchers found.

To calculate treatment rates among parents on Medicaid, the health insurance program for low income people, Tami Mark, a health economist at RTI, who led the research, and her colleagues drew from a new publicly available data set that used de-identified social security numbers to link child welfare records in Florida and Kentucky with corresponding Medicaid claims records from 2020.

For comparison, they also analyzed a random sample of Medicaid recipients who had no records in the child welfare system. (The study didn’t capture any counseling or medication given outside the Medicaid system, nor any cases of mental health or substance use disorders that were undiagnosed.)

Among 58,551 parents who had a child referred to welfare services, more than half had a psychiatric or substance use diagnosis, compared to 33 percent of the comparison group. About 38 percent of those with referrals who had mental health disorders and 40 percent of those who had substance use disorders had received counseling; about 67 percent of people with mental health disorders and 38 percent of those with substance use disorders had received medication.

Norma Coe, an associate professor of medical ethics and health policy at the University of Pennsylvania, who was not involved in the research, said some of the rates were worse than general Medicaid treatment figures , suggesting that some barriers could be specific to parents.

“In general, the U.S. supports parents and caregivers less than many other countries,” Dr. Coe said, “which has numerous and lasting intergenerational effects on health and wealth.”

What Happens Next: Examining the barriers.

The study’s authors highlighted an array of roadblocks to receiving counseling and medication, including stigma, inconvenience and the fear of losing parental rights.

They called for better coordination between social programs, such as integrating the data systems of child welfare and Medicaid so that it would be clear when parents needed to be connected to specific services.

But Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University who studies inequity, said there was another challenge: a shortage of treatment providers that will accept patients on Medicaid, which pays lower reimbursement rates than private insurers.

“Access to behavioral health services is inadequate in the United States,” he said, “but it’s even worse for Medicaid beneficiaries.”

Emily Baumgaertner is a national health reporter for The Times, focusing on public health issues that primarily affect vulnerable communities. More about Emily Baumgaertner

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40 facts about elektrostal.

Written by Lanette Mayes

Modified & Updated: 02 Mar 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy, materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes, offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development.

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy, with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

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