Introduction
This chapter is a review, analysis, and reporting of previous research studies that have examined the challenges experienced when diagnosing and treating individuals with co-occurring disorders as well as identifying predictors of treatment outcomes. Military personnel affected with substance use disorder and co-occurring psychiatric disorder typically receive treatment in parallel settings despite the research supporting an integrated model for treatment (Brooke Army Medical Center, 2015). In any setting where treatment of the disorder takes place, the stakeholders advice that apart from treating the disorder only, the trauma caused by the people need to be curbed if they seek to succeed in their mission of treatment (McCauley, Killeen, Gros, Brady, & Back, 2012). It is important for clinicians to understand what factors impact the recovery process positively or negatively for individuals with Substance Use Disorders (SUDs) and co-occurring psychiatric disorders. Policy makers, program managers, and clinicians must be informed about evidenced-based practices in order to address barriers to treatment and provide integrated services to the military personnel with substance use and co-occurring psychiatric disorders.
This chapter is organized into three sections: Practice Guidelines for Assessment and Treatment of Substance Use and Co-occurring Disorders, Evidenced-Based Therapeutic Interventions for Treating Co-occurring disorders and Predictors of Treatment Outcomes for Substance Use Disorders and Co-occurring Psychiatric Disorders. In each section, the literature review will address the following research questions:
- What are the most effective treatment approaches for the military personnel with substance abuse and co-occurring psychiatric disorders?
- What barriers or theoretical differences occur when treating civilian and military patients with substance abuse and co-occurring psychiatric disorders?
- What practice differences occur when treating civilian and military patients with substance abuse and co-occurring psychiatric disorders?
- What are the best predictors of treatment outcomes for military personnel with substance use and co-occurring psychiatric disorders?
Practice Guidelines for Assessment and Treatment of Co-occurring and SUDs
The SUDs are most prevalent and to a large extent co-occurs frequently affecting the life of the military personnel as well as civilians. If the Comorbid SUD is compared to other disorders, we realize that it is majorly allied to a complex and costly medical course. This medical course is faced with numerous obstacles including the poor public functioning, increased rates of attempted suicide cases, increased risk of fierceness and less improvement of one’s health status during the treatment period (McCauley et al., 2012).
Assessment of SUDs and Co-occurring Disorders
It has been acknowledged that for effective treatment of the comorbid SUDs, assessment of the symptoms of the disorder is essential (McCauley et al., 2012). The main objectives of the assessment include detecting the distress of exposure and the behaviors of people after substance use, appraisal of SUD analyses, and the ongoing evaluation of the symptom rigorousness during the process of treating those affected with the disorder. The assessments are very crucial to the stakeholders since they provide instrumental information that is used during planning for treatment and the monitoring progress. Based on McCauley et al. (2012), the assessment process of SUDs has been made easier due to the establishment of various assessment tools that have been subjected to a thorough investigation process. Therefore, the subsequent sections on the disorder assessment process focus mainly on the fundamental measures that are applicable during the diagnosis process, the treatment monitoring progress, and the treatment planning process for comorbid SUDs. According to Antony and Barlow (2011), the process of assessment comprises of various steps including initial screening that is majorly conducted at non-specialty hospitals, long analytic interviews, self-report checking forms, symptom questionnaires, as well as the biological examinations on the affected people.
Initial Screening
Initial screening is crucial for effective treatment of the disorder. The ability to screen and identify individuals with just alcohol or drug problems is widely known, acceptable, and is readily available around the globe. However, identifying and screening people with SUDs and co-occurring disorders has also been considered to be a challenging exercise that consists of many implications on treatment and outcomes among the patients (Rosenthal, Nunes, & LeFauve (2012). As the world is advancing, more and more tools have been developed to aid during the process of screening to determine the exposure to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the stressful events accompanying the disorder and the challenging substance use among the people. According to Bufka and Camp (2010), the screening tools have been found to be relevant in situations that require individuals to collect huge amounts of data within a short period. This can be done at the various primary care clinics around a state.
According to Antony et al. (2011), the screening measures for the SUD and co-occurring disorders have been studied extensively and are the most used approaches during the assessment process regarding the disorders. Among the screening measures, there is the popular alcohol screening measure that includes the Alcohol Use Disorders Identification Test (AUDIT), CAGE Questionnaire, and the Michigan Alcoholism Screening Test (MAST). Apart from these measures, there are other parallel versions that have been established to cater for drug abusers. They include the Drug Use Disorder Identification Test (DUDIT), The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and the Drug Abuse Screening Test (DAST) that were constituted by World Health Organization (McCauley et al., 2012). These measures are highly commended by the National Institute on Drug Abuse (2009) that regards them as a comprehensive screener that has been developed to help the primary health care specialists. They are applicable to the assessment process to detect and manage the range of SUDs as well as other co-occurring disorders and their associated glitches among the military personnel.
According to Bufka and Camp (2010), the assessment process allows the stakeholders to apply biological tests for alcohol and drug use among the military personnel. The biological test approach is most appropriate since it is easier to collect data widely in this medical setting. This approach involves the use of the blood tests, a breathalyzer test, as well as the urinalysis test during the screening process. The biological tests act as alternative methods for SUD assessment. The most commonly used approach is the urinalysis that is embraced by the authority when they want to detect and assess illicit drug use among persons across the military camps (McCauley et al., 2012). It is cost effective, minimally intrusive and offers a wide range of services including checking for the pattern, amount as well as the frequency of the substance use. Due to its long use in the medical fraternity, most of the drawbacks associated with it have been determined and addressed appropriately. One of its limitations comprises of the narrow window of detection that is usually less than three days after the substance usage (McCauley et al., 2012). SUDs and co-occurring disorders screening does not only depend on urine analysis but rather focuses on other body fluids including blood and saliva (Fischbach & Dunning, 2009).
When the clinicians combine carbohydrate-deficient transferrin (CDT) testing with other disease indicators like liver enzymes, it becomes a better alternative during the screening exercise regarding the assessment of alcohol consumption (Madhubala, Subhashree, & Shanthi, 2013). Apart from the various assessment alternatives that have been discussed earlier, hair analysis method also exists. This method is not used more often, but it is used in quarantine due to the various partialities recognized and the restrictions that emerge during its application on the military personnel (McCauley et al., 2012). Bergström and Helander (2008) found out that the medical practitioners normally do not use blood and saliva samples during the assessment because the cost of administration is high, it involves high intrusiveness and has a narrow detection range. However, when the authorities wish to assess prolonged and heavy alcohol use, they employ blood testing since it the most effective approach among all the other methods discussed earlier.
Diagnosis
A clinical diagnosis of SUDs and co-occurring disorders is conducted after a comprehensive assessment has been carried out regarding the disorders based on the DSM-IV diagnostic criterion (McCauley et al., 2012). According to McCauley et al. (2012), the diagnostic examinations may take several hours to completion and mostly require a lot of training on the stakeholders to administer the diagnosis on the military population as appropriate as possible. This will help the stakeholders to avoid leaving behind traces of incompetency which might result in poor performance based on their duty in the military base or elsewhere. In general, Nienhuis, Van De Willige, Rijnders, De Jonge, and Wiersma (2010) acknowledges that the psychiatric analytical interviews which are aimed at assessing the DSM Axis I mental conditions amidst the military personnel may be appropriate for assessing the comorbidity. For example, the authority can choose to use the structured clinical interview of DSM-IV Axis I D disorder (SCID). This SCID is essential for assessment and treatment of the disorder since it provides reliable and trustworthy diagnostics for SUDs as well as other co-occurring disorders among the military personnel. The assessments and treatment include other interviews that may be semi-structured. They include Anxiety Disorder Interview Schedule for DSM-IV, which is used because of its ability to offer a thorough diagnosis of the SUD and other co-occurring disorders and their symptom severity among the military personnel (Farchione et al., 2012). Consequently, the interviews comprise of the Mini International Neuropsychiatric Interview (MINI) that offers DSM diagnostics although it takes roughly half the time it takes to administer the interviews when using the SCID approach (Martini, Wittchen, Soares, Rieder, & Steiner, 2009). Lastly, the assessment can be conducted using the Composite International Diagnostic Interview version 2 (CIDI-2) comprising of all the major diagnostics on co-occurring disorders and aiding both DSM-IV and ICD 10 criterion (McCauley et al., 2012).
Treatment guidelines are significant for implementing evidenced-based practices. There were only two guidelines found by Perron, Bunger, Vaughn, & Howard, (2010) while completing a systematic review of the treatment guidelines and procedures for substance use disorders and serious mental illnesses among the military personnel and civilians. Perron et al. (2010) found that the treatment guideline authored by the American Psychiatric Association (2013) provided a comprehensive description of the major features of treatment (e.g. case management, family interventions, rehabilitation, pharmacotherapy, and housing) and noted the importance of the same clinicians treating both disorders. The researchers found that this was also the case for Center for Substance Abuse Treatment (2009). Their overall findings resulted in limited guidelines for treating SUDS and Co-occurring disorders.
Psychiatric assessment and management of individuals with SUDs and other co-occurring disorders involves the 1) establishment and maintenance of a therapeutic relationship, 2) continued monitoring of the patient’s clinical status, 3) management of states of intoxication and withdrawal,4) reduction of morbidity, 5) facilitation of treatment plan adherence and provision of educational materials, and diagnosis and treatment of psychiatric disorders (Rieckmann, Fuller, Saedi, & McCarty, 2010).
There is an increased expectation that patients with a substance use disorder have a co-occurring mental disorder if the SUD is relatively serious if the patient began using substances at an early age, is a female, is dependent on nicotine, or has a drug use disorder (Rosenthal, Nunes, & LeFauve, 2012). Both clinical practices and research can benefit from valid, reliable screening methods and diagnostic procedures for co-occurring substance use disorders (Wusthoff, Waal, Ruud, Roislien, & Grawe, 2011). The importance of identifying and treating co-occurring disorders is supported by studies that demonstrate the negative impact the presence of a SUDs could have on the recovery of the military personnel from mental illnesses, including anxiety disorders, bipolar disorder, and schizophrenia (Rosenthal et al., 2012).
Treatment of SUDs and Co-occurring Disorders
Torrens, Rossi, Martinez-Riera, Martines-Sanvisens, & Bulbena, (2012) presented an overview of current opinions pertaining to the choice of site of treatment, the kind of treatment, the kind of intervention, the length of treatment, as well as aims to establish a more effective treatment outcome for individuals with co-occurring and substance abuse disorders. In their study, the researchers emphasized the significant role that diagnostic accuracy plays in the treatment of co-morbid psychiatric disorders in substance users. They acknowledged that accuracy in diagnosing was often problematic. Wusthoff, Waal, Ruud, Roislien, & Grawe (2011) agreed that there has been a mounting evidence of high prevalence of SUDs in our general population, however; they found that despite this strong evidence, there is insufficient application of this knowledge in the clinical practice. These researchers also agree that in order to estimate levels of substance use in a clinical setting, it is imperative that we implement systematic screening procedures with self-administered and validated instruments along with a structured clinical interview and guidelines for practice (Nienhuis, Van De Willige, Rijnders, De Jonge, & Wiersma, 2010).
Treatment of SUD and co-occurring psychiatric disorders
It has been acknowledged globally that the use of psychological as well as the pharmacological means is a significant measure regarding the treatment of SUDs and co-occurring disorders. These two options deal with the behavioral treatment approaches towards curbing the disorders (McCauley et al., 2012). Based on the psychological perspective, the withdrawal from substance use and subsequent yearnings for them raise the potential for their continual use among the military personnel and civilians that are addicted. Consequently, there is increased relapse amid those trying to uphold drug abstinence and recovery procedures (Kelly & Daley, 2013). In dealing with the military personnel, there are no social, cultural or traditional barriers towards the treatment procedure, but for the civilians, the beliefs of people play a major role in the treatment of the conditions. Specific races, tribes and nationals are defined to receive various treatment approaches based on their beliefs (Martini et al., 2009).
Most importantly, based on the longitudinal research it has been found that the treatment effects for any chronic disorder, and the relapse of the illnesses such as obsession reduces over time (Donovan et al., 2008). According to Donovan et al. (2008), the patients affected by the disorders remain in the treatment process, perhaps in a low-intensity case management during the periods of decrease regarding the effects of the disorder. There is room for correction if things proceed otherwise. For instance, supposing there is an increase in stress or that patients report a higher rate of desires for the drugs and lapses that may dim and threaten the recovery process, the process of treatment can be attuned in the earlier stages to help the patients in upholding their stability. Case management services majorly provided by the social workers normally offer services nonstop. This has made the process to be effective in diminishing drug use and enhancing the psychosocial needs of the patients even in situations when they display low intensities of inspiration for the treatment process like in the case of civilian pregnant women (Winhusen et al., 2008). Consequently, case management is a vital component in maintaining one’s clients in a given society and diminishing the requirement for inpatient management. In a research study conducted on huge Veteran populace suffering from depression and having SUD as well as the high intensity of outpatient, monitoring services revealed that once the patients get discharged from hospitals they have an abstemiously caring outcome against re-hospitalization (Kelly & Daley, 2013). The concentration and kind of outpatient living measures upheld, for instance, the community living amenities, have been noted to impact the substance use penalties and to function (Kelly & Daley, 2013).
Integrated treatment
In contrast to the sequential treatment model, we have the integrated treatment model that is closely associated with the self-medication approach. Based on this approach, SUD is fundamentally regarded as the means of reducing the symptoms of Post-Traumatic Stress Disorder (PTSD) and the numerous negative effects brought by the conditions (Suh, Ruffins, Robins, Albanese, & Khantzian, 2008). The approach acknowledges that the early treatment of the trauma is fundamental to the SUD and co-occurring disorders healing process (Back et al., 2012). Treatment procedures using non-exposure-based combined treatments has been acknowledged to the best treatment method regarding the SUD. The trauma-informed treatment approaches regarding the public substance abuse treatment plans is typically conducted in groups, and it is habitually gender specific. The Trauma Exposure and Empowerment Model (TREM) was initially established for women that were diagnosed with the trauma and austere mental disorders, including the SUDs and co-occurring disorders (Covington, 2008).
Sequential Treatment
From the historical point of view, SUD treatment was basically done deferring the treatment of the trauma caused by the disorder on the person. This corresponds to the sequential model of treatment (Foa, Keane, Friedman, & Cohen, 2008), For the military personnel, in most cases it is almost impossible to deal with these cases appropriately if the stakeholders defer the treatment of the trauma caused by the SUDs and co-occurring disorders on the patient or to the military fraternity. The trauma will worsen the effects of the condition among the people. For the case of the civilians, the society will never be a comfortable place to stay for the affected since the disorder will cause much traumatization on the patient and to the public resulting in isolation.
Evidenced-Based Interventions
According to McCauley et al. (2012), addressing the trauma among the patients affected with SUDs and co-occurring disorders is both manageable and beneficial. Under evidence-based interventions, the exposure-based therapies have been noted to be the most effective approaches for curbing the disorders. Historically, individuals with substance use disorders have been treated in different settings apart from those with other mental health diagnoses, despite being classified by the DSM-5 (APA, 2010).
Evidence-Based Treatments for Psychotic Disorders and SUDs
Since the social workers offer services by delivering case management as well as group or individual services to their clients that are affected by the co-occurring disorders, the work of the medics therefore is to focus on the behavioral approaches using or not using medication (Kelly & Daley, 2013). Researchers now agree that a parallel model which provides for the treatment of both addiction and psychiatric disorder trauma is ideal if there is an integration of the systems. According to researchers, emerging data appears to indicate that the “integrated model” seen earlier can best meet the needs of individuals with substance use and co-occurring psychiatric disorders (McCauley et al., 2012). In the practice setting, health care providers can combine treatment interventions for individuals with co-occurring disorders within the context of the primary treatment relationship or service setting. For example, substance use and psychiatric disorder can be addressed in a combined approach. This approach can allow the service setting to treat both disorders, any related problems, and the whole person more effectively (Kelly et al., 2013). According to Kelly et al. (2013), to realize good results among the military personnel and civilian’s progress regarding treatment of the disorder, both the disorder and the effects must be curbed. The trauma caused by the disorder if not controlled well will make the healing process very difficult and unsuccessful.
There is a necessity to employ a combined effort in treating the psychotic disorders and SUDs among the people. The stakeholders ought to comprehend that the medication only treats the psychosis whereas the behavioral techniques help the affected people to overcome the many challenges brought by the disorders. The challenges comprise of the persistent psychotic symptoms, the negative symptoms that adversely affects one’s social relationships, having cravings for more substances, the social pressures urging them to use drugs among many others (Kelly et al., 2013).
Clinicians working within the substance service system as well as those working within the mental health service system need to develop skills to identify, assess and competently treat individuals with SUDs and Co-occurring psychiatric disorders as part of their standard practice (Staiger et al., 2011). Kaufmann, Chen, Crum, and Mojtabai (2014) compared the prevalence and patterns of treatment seeking and barriers to alcohol treatment among individuals with alcohol use orders with and without co-occurring mood or anxiety disorders. They found that individuals with alcohol use disorders and co-occurring mood or anxiety disorders were more likely to seek alcohol treatment. According to Drake, O’Neal, and Wallach (2008), the experienced medics have identified that it is necessary to integrate treatment together with their engagement in motivational counseling since it matters a lot during the healing process among the military personnel as well as civilians. They used data from the national epidemiologic survey on alcohol and related conditions to examine alcohol treatment seeking, treatment settings and providers, perceived an unmet need for treatment and barriers to such treatment. The patients who normally experience transient psychosis due to substance usage have a likelihood of experiencing a recurrence of the psychosis if they continue using the drugs. This, therefore, calls for a lot of motivational counseling to warn them of the effects of the continuing use of the illicit drugs among the people including the military personnel (Fallon, 2008). Research has concluded that individuals with alcohol use disorder and co-occurring mood or anxiety disorder would likely benefit from the expansions of financial access to alcohol treatments and integration of services. This study further highlighted the need for integration of substance and mental health services (Drake et al., 2008).
Horsfall et al. (2009) reviewed a number of existing approaches considered to be effective for treating individuals with substance use disorder and co-occurring psychiatric disorder including MI, CBT, contingency management, relapse prevention, case management, social skills-straining and individual counseling, group counseling, and 12-step mutual support. The researchers posited that regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have the specialist-trained personnel, include a range of program types, and proved for long-term follow-up.
A later study conducted by Perron, Bunger, Vaughn, & Howard (2010) examined
the degree to which practice guidelines targeted for the treatment of substance use disorders addressed the treatment of co-occurring disorders. The researchers found that none of the guidelines made recommendations for treatment of co-occurring disorders or included outcomes that specifically targeted both substance use and mental health disorders. According to Kelly and Daley (2013), it is fundamental to apply the transtheoretical treatment model when integrating services. The model is mostly regarded as a phase of transformation in which the patients are categorized into five phases based on their perception of substance use. The first stage comprises of those who do not view illicit drug use as an issue to them or the society and is called the pre-contemplative stage. Those who acknowledge that drug use is a problem that ought to be tackled with immediate effect are categorized in the following phases; contemplation, planning and action (Kelly & Daley, 2013). The model is fundamental since it makes the treatment services readily available to the patients where they are, and it helps individuals in maintaining a therapeutic cooperation allowing them to be active in the therapy exercise and remain intact throughout the treatment process without opting out (Prochaska, 2013).
Staiger et al. (2011) found out that the treatment needs of individuals with co-occurring disorders were largely overlooked and that there are significant barriers to the treatment process. Some of those barriers included access to care and wider environmental issues such as stable housing, future employment, and social support. According to the researchers, even with fully integrated treatment considered the best practice, the majority of individuals with substance use disorders and co-occurring psychiatric disorders are being treated in separate systems. These researchers hypothesize that clinicians working within each discipline need to develop skills to identify, assess and competently treat these complex cases as a standard practice (Staiger et al., 2011). They ought to apply motivational interviewing (MI), Cognitive-behavioral therapy (CBT), CM, and various models of family therapy (Kelly & Daley, 2013).
Group therapies are essential in a person’s treatment life since they help the stakeholders to conduct a follow up with their clients to ensure their health is in good shape. Based on the recent study on the effectiveness of the treatment approaches it has been found that the combination of MI, CBT, as well as the family therapy methodologies can be effectual in reducing drug use among the clients affected with schizophrenia in a span of one year (Barrowclough et al., 2010). According to a study by Lang et al. (2010) regarding treatment compliance among patients suffering from schizophrenia, more than half of their population had either stopped using their prescription or otherwise had become non-compliant in one way or the other. The patients who were found to be compliant with the medicine prescriptions after one year of their major treatment were suffering from other diseases other than SUD and they had been provided with a moderate intensity medication treatment (Kelly & Daley, 2013).
The Value of Combining and Intensifying Treatments
There is a combined technique that has been established comprising of setback prevention plans and short-term objective setting. It combines MI and CM and is termed as the Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness (BTSAS) (Drake et al., 2008). The fundamental part of this technique is for the patients to be determined in setting up objectives regarding their treatment process (Tenhula, Bennett, & Strong Kinnaman, 2009). The significance of the BTSAS is to retain the patients in the treatment process as well as help in terminating the use of substance among the people. There are specific treatment strategies, therapies, or techniques referred to as interventions which are used to treat one or more disorders. Some of the interventions may include psychopharmacology, 12-Step recovery, individual or group counseling, cognitive-behavioral therapy, motivational enhancements, or other strategies. Individuals might receive these interventions in community-based, inpatient, or residential settings (Drake et al., 2008; Tenhula, Bennett, & Strong Kinnaman, 2009).
Researchers have identified several approaches for treating individuals with substance abuse and co-occurring psychiatric disorders. The initial challenge is engaging and sustaining the patient in the treatment programs. Many individuals with substance use disorder and co-occurring psychiatric disorders tend to be harder to engage and more frequently drop out of long-term treatment programs (Curran, Stecker, Han, & Booth, 2009). For instance, patients with schizophrenia have been found to be more vulnerable to the harmful effects of cannabis due their feelings in the endogenous cannabinoid organization and because of their precise response to these exogenous cannabinoids. If these patients do not receive rigorous case managing services as well as specialized psychotherapeutic facilities, they might feel rejected and opt for relenting the treatment process. Case management on those affected by the disorders is very critical since it reduces the chances of the patients from being hospitalized again (Kelly & Daley, 2013).
The Role of Social Workers in the Intervention Process
The health stakeholders ought to come up with technical assistance centers where social workers play a major role in supporting the implementation process for the agencies. The implementation involves devising Integrated Dual Disorders Treatment (IDDT), an evidenced–based practice for adults with co-occurring substance and mental disorders (Brunette, Dianne Asher, Whitley, Lutz, Wieder, Jones, & McHugo, 2008). In their report, they highlighted the problems and service needs of adults with co-occurring disorders and provided a description of the IDDT model. They also discussed implementation barriers and the role of technical assistance centers. The authors developed an implementation framework using the five stages of change model including 1) Pre-contemplation (unaware or uninterested), 2) Contemplation (consensus building), 3) Preparation (motivating), 4) Action(implementing) and 5) Maintenance (sustaining). To illustrate the implementation process, they used the experiences of the Ohio Substance Abuse and Mental Illness Coordinating Center (SAMI CCOE). The authors concluded that there are several lessons learned in helping organizations to implement integrated treatment for adults with co-occurring disorders.
The Social workers to a large extent do help the patients suffering from the disorders by aiding them to stay in the recovery process by adhering to their low level of emotionality amidst establishing a strong connection with their patients (Stevens, McGeehan, & Kelleher, 2010). They also uphold intervention approaches that strengthen the value of the patients having a low level of emotionality in other associations. Researchers suggest that the low emotionality among the patients is linked to the low stimulation that has been found to be strongly connected to the patient’s improvement progress (Kelly & Daley, 2013).
Predictors of Treatment Outcomes
Military Aspects and Culture
Some unique military organization aspects and culture have been recognized to affect the utilization of health services and help to seek. The basic rules of the military career mandate the leaders to control their subordinates in such a way to determine when one can receive help. They also determine when the professional health conditions can be evaluated and indicate when treatment is needed (Tanielian & Jaycox, 2008). Therefore, in this case, the military personnel suffering from substance abuse and mental disorders cannot seek medical treatment without a clear permission from their leaders. Mostly, these restrictions tend to delay the time that an individual is required to seek help. More so, the military culture influences the help-seeking behavior. The military ethos and values involve duty, loyalty, honor, selfless service, and personal courage. The ethos grounded in these values explains a code of conduct that entails putting the mission first, never quitting, and never accepting defeat. Therefore, being sick is contrary to these codes and may inhibit the veteran from seeking help for a psychological or substance abuse disorder (Tanielian & Jaycox, 2008).
Bray et al. (2008) recognize that policies and regulations may inhibit the military personnel from getting the treatment against substance use disorders and PTSDs. A zero tolerant policy on drugs including prescriptions may inhibit the veterans from utilizing the health services at the right time. In addition, health service providers have reported that it is difficult for militaries to obtain time off from military duties to attend treatments. The deployed militaries have limited access to proper care (Kim et al., 2010; and Joint Mental Health Advisory Team 7, 2011). Therefore, the treatment outcomes mostly will depend on the policies set by the military leaders.
A study conducted by Gorman, blow, Ames & Reed (2011) shows that a military personnel seeking help may portray a perceived weakness and therefore affect self-concept negatively. In the same study, the researchers discovered that some negative consequences may occur from the disclosure of a psychological disorder or substance use. The militaries also avoid looking for help due to fear of losing their jobs. Since alcohol abuse is prohibited during deployments, individuals fail to seek help or discontinue treatment due to the fear of losing the deployments (Gorman, Blow, Ames, & Reed, 2011).
Unit leadership has been discovered to be the key factor that would influence people in seeking mental health services. Another research discovered some factors that might support the exploitation of the military mental services by the veterans. The research revealed that High-quality leadership is negatively correlated with mental health stigma as well as the mental health problems. Therefore, good leadership can be helpful in sustaining mental health, mitigating negative combat effects and serving as a facilitator to seeking mental health services, which would result in a positive treatment outcome (Garvey Wilson, A., Messer, & Hoge, 2009).
Stigma
Stigma is also considered a predictive factor for the treatment outcomes. A study conducted by Haskell et al (2010) detected that veterans returning from Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF) and testing positive for a mental health disorder portrayed various attitudinal obstructions to looking for treatment. According to the results of the study, 63% of the victims noted that they would be seen as weak, and 65% said that their leaders would treat them differently. Fifty-five percent of the victims were unable to get time off work while 50% would face negative career implications. The overall results indicated that 38-45% respondents were interested in seeking assistance while only 23-40% had received help. The military personnel approaching the conclusion of their deployment were also afraid that admitting a problem may result in their earlier exit. Concerns about the stigma were the greatest among those who needed help (Haskell et al., 2010).
The social stigma attached to seeking professional treatment has been acknowledged to be the most important predictor of treatment outcomes in veterans with SUD and mental problems. This may be as a result of the public tending to give negative descriptions of the people who suffer from mental illness (Haskell et al., 2010). Some researchers have discovered that being branded as “a former mental patient” results in more social rejection across the military fraternity. The stigmatization caused by the branding of the veterans has been discovered to negatively affect the treatment seeking procedure among the military personnel (Haskell et al., 2010).
Personal Factors
Relationships tend to predict much on how often military personnel with SUDs and PTSD will seek treatment (Gladding, 2012). Studies acknowledge that women with SUDs and PTSD have trouble in communicating their problems since they may lack trust (Gladding, 2012; Sayers, Farrow, Ross, & Oslin, 2009). Moreover, marriage problems and disagreements encountered by the military personnel leads to negative outcomes regarding seeking treatment or disclosing their problems (Sayers, Farrow, Ross, & Oslin, 2009). The relationships with one’s family, coworkers, and friends changes once a veteran experiences different kinds of trauma. As the affiliations change the chances of disclosing one’s problem and asking for help diminishes (Gladding, 2012). On the contrary, healthy relationships can promote the wellbeing of military personnel with co-occurring SUDs and PSTD. The support from partners can be essential in motivating the victim to seek medical attention thus enhancing their recovery process (Center for Substance Abuse Treatment, 2009).
Further studies point out the aspect of gender as a predictor of how often patients with SUDs and PTSD obtain treatments. More women encounter traumatic experiences than men. It has been noticed that women experience military sexual trauma more often than men and over half of the sexual abuse experienced by female servicewomen occur when they are on duty (Foa, Keane, Friedman, & Cohen, 2008). The military sex trauma has been reported to be the leading spike in the development of PTSD. Due to many traumatic experiences encountered by the female veterans, their treatment is faced with a lot of challenges since they do not normally open up. The military environment tends to be unsupportive to female. The sexual harassment together with the disorders affects the women’s self-esteem thus weakening their chances of seeking for any health assistance. (Hyun, Pavao & Kimmerling, 2009)
The attitude of the military patients with the SUDs and PSTDs has been reported to have a direct impact on the treatment outcomes. According to Kimerling, Kulkarni, Bonn-Miller, Weaver Trafton (2014), veterans with negative beliefs towards SUDs and PTSDs treatment do not seek medical services . They also discontinue their treatment within a short time. Some of them hold on to the belief that the use of physiological treatment may affect their reputation while others believe that seeking treatment is a sign of weakness and may indicate that one is not competent in the job (Hawkins et., at 2012).
Researchers have pointed out that many veterans suffering from addiction and posttraumatic stress disorders use treatment fears as an avoidance factor. (Blonigen, Bui, Harris, Hepner, & Kivlahan, 2014). The treatment fears are defined as the state of uneasiness cropping from the expectation pertaining the seeking of mental health services. The fears are concerned with how the medical professionals treat their patients when they seek help. One study discovered that these fears may lead to avoidance or delay in seeking treatment (Blonigen, Bui, Harris, Hepner, & Kivlahan, 2014). Other studies discovered that many patients who do not seek for mental health services have the worst treatment fears. However, based on contradicting researchers, treatment fears have been reported to predict the intentions of seeking medical assistance for military personnel suffering from psychiatric problems (Morrison, Berenz, & Coffey, 2013).
The fear of emotion has also been discovered as a predictive factor for treatment outcomes. According to Morrison, Berenz, & Coffey (2013), most people with the mental problems avoid seeking counseling services due to the fear of discussing their painful emotions. Studies show that seeking help from a different person entails strong emotions, which many patients may be unwilling to disclose. In a study to examine emotional expression by militaries, Morrison, Berenz, & Coffey (2013) found out that their unwillingness to seek treatment was greater in patients who were not open about their emotions. In the same way, patients who were less skilled in dealing with emotions were found to be reluctant in seeking for medical health services. The fear of discussing one’s emotions prohibits most patients from seeking mental help, and thus, their overall treatment outcomes against addiction and posttraumatic stress conditions are weakened.
Medical Care Factors
Treatment duration can affect the outcome of the SUD and PTSDs. Diverse studies have found that the length of treatment is associated with the treatment outcomes. The studies discovered that the longer the time the military patients are subjected to the treatment process, the higher the chances of reducing their substance cravings (Krupski, Campbell, Joesch, Lucenko, & Roy-Byrne, 2009; and Walker, 2009). In a related concept, another research indicated that the access to post-treatment services leads to positive treatment outcomes. The study showed that continuing treatment past SUD rehabilitation by accessing the PTSD assists in recovering the addicts thus producing positive treatment outcomes (Walker, 2009).
Location of treatment centers or geographic separation has been identified as a barrier to military health services. Researchers acknowledge that the treatment centers, especially in a deployed setting, are located far from the duty sites making it hectic for the SUD and posttraumatic stress patients to access treatment. Therefore, geographical separation of the health services contributes negatively to the treatment outcomes (McDevitt-Murphy, Monahan, & Williams, 2012).
Sloboda, Glantz, and Tarter (2012) evaluated a brief intervention designed to facilitate outpatient engagement following an inpatient psychiatric stay for individuals with mental illness and substance use. They looked at (1) Time Limited Care-Coordination (TLC), an eight-week co-occurring disorders intervention and (2) a matched attention (MA) control condition in the form of health education sessions. The outcome of the study indicated that an eight-week intervention could improve the treatment process and that the TLC intervention mitigated some of the problems that occur due to a lack of coordination between service systems. According to Dixon et al. (2009), a three-month Brief Critical Time Intervention (B-CTI) was developed to assist in the treatment process during a patient’s transition from inpatient to outpatient care. In his study, patients had fewer days between their hospital discharge and their first outpatient visit and ultimately participated in a total mental health and substance abuse treatment visits. The continuity of care ensures there are no gaps in the treatment process and strengthens the patients’ motivation and engagement in treatment.
Timko, Sutkowi, and Moos (2010) compared outpatients with substance use and psychiatric disorders on the baseline and one-year symptoms, and treatment and 12-step group participation over a course of one year. They examined whether diagnostic status moderated associations between participation and outcomes with regressions. Their findings indicated that outcomes were weaker for dual diagnosis patients when assessing their level of participation in the 12-step groups. Specifically, they found that different aspects of 12-step group participation predicted different outcomes. In patients with psychiatric disorders, working more steps and having a sponsor were found to be associated with better alcohol, drugs, and psychiatric outcomes. On the other hand, those attending more 12-step group meetings and having a sponsor were associated with better alcohol and drug-use-related outcomes. The risk for relapse and poor outcomes was also found to be a primary concern for individuals who abuse drugs.
Type of treatment
The report filed by the U.S Department of Veterans Affair in 2013 affirms that the type of treatment that patients received determined the treatment outcome (Blonigen, Bui, Harris, Hepner, & Kivlahan, 2014). All patients diagnosed with dual substance use and psychiatric disorders received an intensive or standard referral once they opted to seek for an outpatient mental health. The intensive referrals were mostly associated with better psychiatric treatment outcomes than the standard referrals. The findings showed that attending more intensive referrals increased the readiness of the patients to attend the self-help groups that were associated with a better psychiatric and alcohol outcomes at six months (Blonigen, Bui, Harris, Hepner, & Kivlahan, 2014). In the same context, a more recent study acknowledges that treatment track systems may be useful in improving the treatment outcomes in patients with PTSD and SUD (Boden et al. 2012). The patients who were disposed to seeking safety track reported reduced incidences of abuse. More so, the patients showed considerable improvements in mental health functioning, PTSD symptom severity and reduction of legal issues. The researchers implied that Seeking Safety (SS) – based track might be essential in improving treatment attendance, drug use outcomes, surviving the six -month treatment engagement and treatment satisfaction (Boden et al. 2012).
According to Riper et al. (2013) combined CBT and MI for clinical or a subclinical depressive and alcohol use disorder were determined to have a small but clinically significant effect on treatment outcomes compared to treatment as usual. A brief session on alcohol interventions was suggested as the first-step treatment for co-occurring alcohol problems followed by a more intensive treatment on the patients who do not respond adequately.
Treatment satisfaction was also considered as a method to predict outcome and sustained recovery (DeLeon, 2010; Schulte, Meier, & Stirling, 2011). Schulte, Meier, and Stirling, (2011) completed a systematic review of the existing evidence regarding treatment satisfaction among clients with substance misuse and mental health co-occurring disorder. From their review, it was acknowledged that integrated treatment delivery addressing both addiction and mental health concerns, resulted in high levels of patient satisfaction. Prior to the opening of our RTP, Schulte, Meier, and Stirling (2011) had the opportunity to facilitate three iterations of a co-occurring treatment track using an integrated treatment approach. Patients appreciated the continuity and remained hopeful that this will lower their relapse rate and reduce the severity of their symptoms.
Curran et al., (2009) conducted a study to investigate patient and program-level variables associated with attrition from Intensive Outpatient Program (IOP) substance use and treatment using a national Veteran Affairs (VA) sample. In their study, they used National databases to identify a cohort of patients receiving intensive IOP substance use treatment. To complete this study, the authors examined patient-level variables consisting of age, gender, race, and psychiatric and medical comorbidities. They found that being older, female, and having psychotic disorder was associated with attrition. They also considered program-level factors and found that the number of hours the program offered treatment was related to attrition rates. Basically, more treatment was associated with higher attrition. In their report, they discussed implications on Behavioral Health recommending that VA IOP programs focus on interventions to improve retention among female patients. They further recommended that therapy groups focusing solely on women patients or their issues will increase the likelihood that women patients with substance use disorders will receive adequate treatment in the VA.
A study involving 120 OEF/OIF returnees indicates that about 33% of the participants encountered alcohol abuse, but only 18% of those testing positive for alcohol misuse were reported to be using health and support services (Erbes, Westermeyer, Engdahl, & Johnsen, 2009). In contrast from the 12% who screened positive for PTSD, 56% were reported to use mental health services. This report indicated that there were high rates of unmet treatments for mental health and SUD problems (Erbes et al., 2009). The report was similar to a special report documented on the needs of 900 New York returning patients (Schell & Tanielian, 2011). It outlined that half of the sample had a need for treatment defined by self-indicated need or probable diagnosis. According to this report, about one-third of those with treatment needs had sought for mental health services, but just about half of those who had sought medical help obtained treatment (Schell & Tanielian, 2011). In other words, in an approximate of 450 patients with treatment needs, only 18% received treatment. Similar studies have also indicated how the rate of unmet needs has influenced the treatment outcomes. For instance, Substance Abuse and Mental Health Services Administration (SAMHSA) used National Survey on Drug Use and Health (NSDUH) to provide articles that addressed the unmet needs of the patients with mental problems. Based on the articles that were produced, the results proved that 60% of the patients (aged 21-39) with a Major Depression Episode(MDE) received treatment (Golub et al., 2013). A more recent analysis of NSDUH data from 2004 to 2010 focusing on the young patients at the age of 21-34 produced comparably approximates. Among those who screened positive for serious disorders, 43% received treatment whereas, among the SUD patients, only the treatment needs of only 11% of the patients were met (Golub et al., 2013).
Spiritual Factor
Spirituality is a versatile factor that may influence veteran’s resurgence from posttraumatic stress disorder (PTSD) in maladaptive and adaptive ways. Currier, Holland and Drescher (2015) examined the longitudinal connection between spirituality and the severity of PTSD symptom. The results showed that the spirituality factors were highly predictive of the severity of PTSD symptom at discharge. Patients who scored better in the adaptability of spiritual factors fared better in the treatment program. Patients who had spiritual struggles had difficulties in adapting to the treatment programs. The researchers suggested that understanding the spiritual context of the patients with the PTSD might help the clinicians while administering treatment programs to improve the results of the treatments (Currier, Holland & Drescher, 2015).
In the same sense, Koenig (2013) carried out a systematic study to review the relationship between spiritual involvement and health outcomes of the patients who suffered from substance abuse and mental problems. He discovered that religious practices of the veteran’s belief were highly related to wellbeing and emotional health. Koenig (2013) revealed that patients who seek spiritual advice after suffering from SUD obtain a lot of social support and are less isolated. They achieve more life expectations. Their desire to live healthy lives push them towards seeking for medical treatment. These religious beliefs and practices are valuable assets to the recovery of soldiers from trauma and self-restoration. However, researchers suggest that treatment providers should not impose cultural or personal template uncertainty since it may lower the counselor efficacy in treating trauma survivors (Jones & Cureton, 2014).
Family and Social Support
Studies have shown that socioeconomic factors are some of the greatest preexisting factors that may predict the outcome of SUD and PTSD treatment. The relationship between the social status and the worst outcome of the treatment may be due to the limited resources available to the family and the veterans. They include access to high military treatment, especially when the patients are back home (Jonas et al., 2013). The negative treatment outcomes are also associated with the unavailability of family members to work as caregivers at home. Due to work limitations or other responsibilities, the family members may be unable to offer the support system and help that the patients need after hospitalization.
According to Levack et al., (2009), successful treatment and rehabilitation require cooperation in areas such as finances, transportation, emotional support, and leisure. From a healthcare perspective, family members provide the largest portion of care needed to assist the patients with substance abuse and psychiatric disorders (Kreutzer et al., 2009). On the other hand, unhealthy communication and family stress can hinder the rehabilitation or treatment progress of the patients. Kreutzer et al., (2009) agrees that family functioning has been associated with blocking or facilitating the treatment progress and improving the psychological distress disorder.
The nature of Traumatic Events
There are many traumatic events that come in hand with the military work (Jones et al., (2012). Studies have shown how patients experience adverse traumatic events that worsen their addiction or their post traumatic disorders (Greenberg et al., 2011; & Jonas et al., 2013). Post- incidence psychiatric problem is evidenced in patients who involve in recurrent traumatic events (Greenberg et.al, 2011). Researchers agree that the feeling of fear, helplessness, and horror that this service people face in their line of duty elevates their problem, and it limits the recovery of the patients from substance addiction and other mental problems (Greenberg et al., 2011; & Jonas et al., 2013). The SUD patients undergoing a recovery treatment tend to go back to the substance abuse behavior after experiencing the traumatic events (Jonas et al., 2013). Consequently, chances of recovery are lowered, and the treatment outcome becomes weak. Some of the traumatizing events reviewed by some studies include torture, war, and disasters. The women patients are also more prone to rape and other forms of sexual assaults, and therefore, they tend to suffer more trauma than their male counterparts (Jonas et al., 2013).
Moral injury associated with traumatic or war activities may inhibit the military patients from seeking help. Brock & Lettini (2012) argued that the wars in Afghanistan and Iraq left many soldiers vulnerable to moral injury. The upshot of the mental torment may cause haunting states to the soldiers. The soldiers exhibit emotional responses to shame, guilt, anxiety, and anger. The emotional responses act as an obstruction to the patients who opt to continue with their SUD and PTSD treatment. Additionally, moral injury results in some behavioral manifestations such as self-condemnation, which leads to withdrawal from the treatment programs (Nash & Litz, 2013).
Conclusion
The review of literature on the Addiction and Co-occurring psychiatric disorders has revealed that various challenges are experienced during the assessment and treatment of military personnel as well as civilians suffering from SUDs and Co-occurring psychiatric disorders. These challenges include the cost endured in administering the various treatment methods. Some of the interventions are cost effective whereas others are very expensive. Some of the predictors of treatment outcomes include Military aspects and culture, stigma, personal factors, type of treatment, medical care factors, the nature of traumatic events and family as well as their social support. This review has also revealed that it is difficult for the military personnel affected to open up and report their cases for fear they might lose their job. Moreover, the military personnel suffering from SUDs and co-occurring psychiatric disorders are exposed to parallel treatment settings rather than adopting the integrated treatment model that has been proved to be the most effective approach. Integrated services are essential to the military personnel affected with substance use and co-occurring psychiatric disorders. The integrated treatment model is fundamental since it ensures both the disorder and its trauma are contained if good results have to be realized. Consequently, it is vital for the medics to comprehend the factors affecting the recovery process of the veterans suffering from Substance Use Disorders and co-occurring psychiatric disorders. The national policymakers, program administrators, and medics ought to be informed regarding evidenced-based practices that can be used to address barriers to successful treatment.
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