Co-Occurring Behavioral Health Conditions

The presence of comorbid behavioral health conditions can significantly affect a patient’s engagement in treatment, adherence to treatment plans, and patient-provider interactions. Also, it can be challenging to properly diagnosis and treat comorbid disorders because it may be difficult to determine the underlying cause of overlapping symptoms.¹

Screening for mental health or substance use disorders may occur at the initial intake as it can help identify certain triggering symptoms and may help identify a co-occurring disorder. Providers should consider observing patients and potentially rescreening them after they have abstained from opioid use for a period of time to help differentiate between the symptoms of substance intoxication or withdrawal and comorbid mental health disorders.¹

At a minimum, providers should screen for these behavioral health conditions:

• Depression—Patient-Health Questionnaire (PHQ-9) (PDF—40 KB)
• Anxiety—Generalized Anxiety Disorder 7-item (GAD-7) (PDF—130 KB)
• Post-Traumatic Stress Disorder (PTSD)—Primary Care PTSD Screen (PC-PTSD) or Life Events Checklist (LEC) (PDF—2036 KB)

Other psychiatric disorders or mental health conditions that may affect a patient’s well-being and treatment for opioid use disorder include bipolar disorder, attention-deficit/hyperactivity disorder, borderline personality disorder, and antisocial personality disorder.

As discussed in the earlier section on Screening and Diagnosis of opioid use disorders, the following screening tools can be used to identify those with or at risk for substance use disorders across several conditions:

• Alcohol Use Disorders Identification Test (AUDIT) (PDF—224 KB)
• Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS)
• Alcohol Smoking and Substance Involvement Screening Test (ASSIST) (PDF—332 KB)
• NIDA-Modified ASSIST: Quick Screen (NM ASSIST)
• CAGE-AID (PDF—27 KB)
• Drug Abuse Screening Test (DAST) - 10

After a patient screens positive for a co-occurring behavioral health disorder, providers should gather additional information that can help inform treatment planning. This assessment should seek to³:

1. Obtain a more detailed history of past mental health or substance use symptoms, diagnoses, treatments, and impairments;
2. Screen for suicide risk, as risk of suicide is increased substantially among individuals with behavioral health disorders (see the next section on Suicidality for more details);
3. Understand the patient’s current strengths, supports, challenges, skill deficits, and cultural needs or preferences; and
4. Determine the patient’s readiness to engage and goals for treatment.

Based on the patient’s needs and preferences, providers should try to connect the patient with the appropriate treatment, whether these services are internal or external, and adjust the treatment plan as needed.

Treatment of co-occurring disorders often incorporates cognitive behavioral therapy (CBT), which helps strengthen interpersonal and coping skills. A number of platforms and applications are available that provide internet-based CBT through a computer or mobile device. These tools may be particularly useful in areas in which behavioral health services are hard to access or are unavailable.

Other behavioral therapies that have shown promise in treating co-occurring mental health and substance use disorders include dialectical behavioral therapy, acceptance and commitment therapy, and contingency management.² In particular, PTSD may be a condition that not only requires additional, specialized treatment from another mental health provider, but also requires MAT providers and programs to take a trauma-informed approach, as discussed earlier in the Playbook.

In the past, providers would sometimes take a “sequential” approach to the treatment of co-occurring disorders, addressing only one disorder at a time. A preferred approach for patients with interrelated conditions is to develop one care plan with elements to address each condition. Treatment of co-occurring behavioral health disorders may be⁴:

• Parallel—Patients are treated at the same time for both co-occurring disorders in different settings. Collaboration and care coordination between providers will be key if patients are receiving parallel treatment.
• Integrated—Integrated care is a “whole person” approach that blends care for multiple conditions in one setting. Providers and the patient work together as a team to develop treatment plans and manage the patient’s needs and are ideally cross-trained in both mental health and addiction.

Learn more about behavioral health therapies, integrated care, and ways to connect patients with external resources in Behavioral Health Services and Referrals and Care Coordination.