When he arrived in Lisa Fortuna, MD’s office, the young man was homeless, had a history of childhood physical and sexual abuse, and was using “any substance he could get his hands on,” including opioids and stimulants. He had already spent years ping-ponging among treatment programs and felt burdened by their many overlapping requirements — and discouraged by his apparent inability to see the programs through.
“He was having a hard time,” recalls Fortuna, who is vice-chair of psychiatry at the University of California San Francisco and chief of psychiatry at Zuckerberg San Francisco General Hospital. “His addiction was very complicated, but his trauma was also very complicated.”
Data from the National Survey on Drug Use and Health shows that an estimated 64% of adults with substance use disorder (SUD) have reported a co-occurring mental illness within in the last year. However, just less than one-quarter have received treatment for both. When it comes to young adults, Andrea Spencer, MD, a psychiatrist at Boston Medical Center, says the former number may be even higher.
“Our data for the narrow age group that straddles adolescents and adults is more sparse than we would like, but the best data we have suggests there are probably even higher rates of psychiatric disorders in young adults with SUD than there are for all adults in general,” Spencer says.
It’s well known that mental illness and substance use exacerbate each other and increase the risk of relapse and poor outcomes for both conditions. And yet, integrated mental health and addiction care is the exception rather than the rule.
“Often these levels of care are siloed because that’s the way our system is structured,” Fortuna says. “But patients that have a dual diagnosis or coexisting disorders need that comprehensive, integrated care to make a difference in both areas of need.”
A recognition of the gap has given rise to new principles of care for addressing comorbid psychiatric illness in young adults with substance use disorder, as developed in a national convening by the Grayken Center for Addiction and published in a recent Pediatrics supplement. The paper, co-authored by Fortuna, Spencer, and colleagues, outlines three principles.
1. Young adults should receive integrated mental health and addiction care across treatment settings.
Young adults should receive integrated treatment with a team of care providers that includes addiction specialists, mental health clinicians, and medical professionals, says Spencer. In addition to better outcomes, providing integrated care offers more entry points to the healthcare system and more opportunities for engagement with the patient, she notes.
Some young people who aren’t ready to address their substance use may be willing to work on their anxiety or PTSD as a first step, Fortuna says. For others, entering treatment for substance use can be a foot-in-the-door to getting help with underlying mental health concerns. Meeting young patients where they’re at and respecting their agency in making their own healthcare decisions as emerging adults is critical to getting their buy-in and engagement with the process, she says.
“Ideally, we would want to design systems so that there is no wrong door for a patient to enter so that, whether they are identified in primary care or an addiction program, they can access the same amount of care for both disorders,” Spencer explains.
2. Addiction treatment should be responsive to the needs of young adults exposed to trauma and other adverse childhood experiences.
In addition to providing integrated care, clinicians need to approach substance use treatment with an understanding of trauma, including physical and sexual abuse, neglect, and family issues. Research has shown that exposure to childhood trauma increases the risk of mental health issues and addiction later in life, with an estimated 75% of adults in treatment for substance use reporting a history of trauma or abuse.
“We know that childhood trauma is a risk factor for the development of substance use disorders and that kids with a background of significant trauma are more at risk of having problems with their substance use, especially when it becomes a component of self-medication,” Fortuna says.
At the same time, trauma can inform how patients respond to treatment. For example, the stress of withdrawal symptoms can trigger a trauma response in some patients, leading them to self-medicate and increasing the risk of relapse. “It becomes a cycle that can be very difficult to break, which is why integrated care is important,” Fortuna explains.
3. Treatment programs should regularly assess and respond to the evolving mental health needs, motivation, and treatment goals of young adults with co-occurring disorders.
It’s vital that care providers work closely with patients and design a flexible treatment plan to meet their changing needs. This is especially true for young adults, who experience many external and internal changes through their late teens and early 20s. Priorities can shift rapidly from concerns about school to relationships with peers to housing insecurity.
“It’s a constant conversation because what you’re trying to do as a provider is address what is happening in the moment and collaborate with them to address their goals,” Fortuna says.
That was the case with her patient. After spending time working with the young man to figure out his priorities, she started by helping him deal with his immediate needs, including finding safe housing and developing a strategy to protect himself from people who were harming him. The focus then shifted to treating his anxiety and using medication to help with withdrawal symptoms. Once his addiction was stabilized, Fortuna began working with him on his PTSD. Care focused on working collaboratively with the patient in a way that gave him self-determination.
“That in itself is trauma-informed because he felt his needs and concerns were being taken into account, and I was doing so respectfully,” Fortuna says. “In an age where young people are coming into their own and starting to make their own decisions, if you can work with young people and address what their priorities are, listen to them, and walk that path collaboratively, there’s going to be a lot more engagement.”
