Mental Health Co-Morbidity
The Co-occurrence of Substance Abuse and Mental Illness:
Thomas Burns
Springfield College School of Human Services
According to the National Institute on Drug Addiction “comorbidity occurs when there are interactions between two disorders or illnesses and the interactions may happen simultaneously or sequentially in the same person” (2008, p.1). Europeans turn to the International Classification of Disease (ICD) in order to define comorbidity. This definition is reported through the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), who reports that comorbidity means “the presence or coexistence of additional diseases with the reference to an initial diagnoses or to the index condition …show more content…
that is being examined”(Baldacchino and Corkery, 2006).
There are several definitions reflected in the literature of peer reviewed journals and other academic sources. Researchers have indicated that we must first fully recognize drug addiction as a mental illness instead of a moral failing. Drug addiction and other mental illnesses are found to be more common among patients diagnosed with other illnesses, i.e. Hepatitis C and HIV. These secondary illnesses are usually direct results of individual’s drug use and their dependence.
National Institute on Drug Abuse, uses the term “mental illness chemical abusers” in place of comorbid, co-occurring and individuals dual diagnosed. They also assert that drug addiction should be defined as a mental illness, in the same categories as other mental disorders like depression, schizophrenia, anxiety and mania (NIDA, 2010 p.2). Mental illness disorders are made evident by the disorganization of an individual’s personality and emotions that have become seriously impaired.
Drug dependence and drug addiction begin to overlap one another in definition and meaning. Drug dependence however is not considered a mental illness, dependence is defined in the DSM-IV as when individuals build tolerance that requires higher doses and eventually ends with symptoms of withdrawals. Addiction is defined within the DSM-IV as a mental illness because of the compulsivity component, NIDA along with the DSM-IV believe that addiction changes elements of the brain that helps humans beings choose their hierarchy of needs. “Addiction changes the brain, disturbing the normal hierarchy of needs and desire, substituting new priorities connected to procuring and using drugs”(NIDA, 2010 p.2). Still many people continue to ask two very interesting questions about the comorbidity of addiction and mental illness. One question is, which illness evolved first? The mental illness or the addiction? Secondly which should be treated as the primary illness. These question has provoked a broad range of definitions from several different sources that attempt to answer those simple but difficult questions.
According to (NIDA) after surveying several adult individuals, they report becoming confused over the many years of living with the dual illnesses then not remembering which symptom appeared first (2008, p.3). NIDA does provides some the answers by referring to the DSM-IV which states “drug abuse and dependence has the ability to mimic the symptoms of other mental illnesses, such as crack cocaine and marijuana which increases the risk of psychosis” (APA 1994). Furthermore drug abuse and mental illnesses are thought to be caused by some overlapping factors such as genetics, high levels of stress and the experience of a traumatic event.
According to Canadian Journal of Psychiatry when describing comorbidity of alcoholism and mental illness, they believe that “the onset of phobic disorders precede the onset of alcohol use disorder”. Furthermore (CJP) underscores that comorbidity should be treated in an aggressive manner to treat the mental illness to prevent the onset of comorbidity with alcoholism. Moreover the Canadian Journal of Psychology (CJP) describes another alternative to questions by indicating that findings from research suggest that having multiple psychiatric disorders inhibits treatments which is thought to lead to poorer treatment outcome opposed to those with only one disorder (CJP, 2001, p.5 p.26). Another finding written in the (CJP) indicated that individuals with lifetime alcohol abuse or dependence are two to three times more likely of having mental illness disorders develop.
Terminology and definition of co-morbidity cannot be fully agreed upon between most of psychiatry, medical and substances abuse professionals from different parts of the world.
According to European Monitoring Centre for Drugs and Addiction ( EMCDDA) in reference to the relationship between substance use and mental health disorders, they define a general level of co-morbidity as “the coexistence of additional diseases and the reference to an initial diagnoses” (Baldacchino and Corkey,2006). The World Health Organization does not differ much in definition from most other organizational studies but they seem to individualize “mental health” and “substance use” in terms of referring to the co-occurrence of two “psychiatric disorders” not involving “psychoactive substance use” or the co-occurrence of two diagnosable substance disorders (WHO, …show more content…
2008).
Psychiatric co-morbidity does not imply that a relationship with substance use and mental health disorders exist, but they can however be present at the same time or can appear at different times in an individual’s lifetime (Frisher et al., 2009; Langas et al., 2011).
The EMCDDA, agrees with the DSM-IV that co-morbidity in general is difficult to diagnose because of the tendency of the drugs producing the same affects in individuals as mental illness, in addition difficulty also comes in assessing a time span of the two disorders.
Individuals diagnosed with mental health disorders are believed to more likely to use drugs to self-medicate which then goes on to trigger a latent mental health problem. What makes diagnosing even more difficult is that symptoms and their developing process must be diagnosed when they first appear. Lack of different methods for diagnosing and understanding comorbidity of mental illness and substance abuse slowed progress for many years. The most prevalent of methods used to define and diagnose remains in place today use a combination of the same international standard of instruments (i.e.) American Diagnostic Statistical Manual (DSM) and the International Classification of Disease (ICD) that were developed several years ago. Professionals who are defining or diagnosing individuals for comorbidity of mental health and substance abuse have a great influence on the individuals primary diagnoses based on which field they are working. Based on research from several sources it is still no clear evidence of which disorder is more prevalent in society, or if one causes the other. There is still no clear evidence which diagnoses shall be treated as the primary disorder but our methods has produced protocols of treatment that allow professionals to treat at least one at a time. Influence of treatment may still occur based on a providers personal or professional biases.
Social Values underlying Definitions
The different definitions of our social values today are reflected in the evidence of research gathered from mental health and psychiatric professionals and substance abuse professionals. These values are shown academic research and the data from thousands of written articles from United States and abroad. The theories and ideologies are formulated to be more client centered today. The advantage of defining the social values is to create better informed professionals with current and practical information. Ethical and highly skilled professionals are essential for continued effective clinically practice. The ideology and belief system of the majority of researchers promotes the importance recognizing a value system that embodies cultural diversity, individual self-worth, non-judgmental attitudes, respect and dignity.
There are values underlying our conceptualization of mental illness and substance abuse treatment. Professionals that are afforded the ability to participate in defining literature contribute to both positive and negative effects of our social values system. These are the individuals that emulate the importance of human relationships, social justice for the people they serve. Although most social values are usually meant to best serve the individuals diagnosed with co-occurring disorders, there can also be negative impacts resulting from the stigmas of diagnoses.
The social values underlying co-occurrence are endorsed by the mental health and the psychiatric industry. Being diagnosed with any mental illness that implies a defect of character which usually causes individuals to internalize and inter-personalize the label of mental illness and substance disorders. Social values are sometimes identified in combination through individuals that are gay, lesbian or based on their skin color can usually have moral imputation and egregious effects such as self-esteem and self-efficacy decrements.
Not everyone is affected negatively by professional or public opinion of people suffering from a mental illness or addiction. Many individuals become empowered by the belief that everyone has a negative perception of their illness and become advocates for themselves and others who are labeled as drug addicts and mentally ill. However, perception remains to be the driving force, sometimes based on the public value system of individual’s diagnoses. The criminal justice systems view, employers, housing market and even the level of care in our medical and mental health systems have all created policies and legislation driven by the definition of our American social values system.
Case Example of an employment problem by Farina (Farina & Felner, 1973). “A male confederate, posing as an unemployed worker, sought jobs at 32 businesses. The same work history was reported at each of job interviews except 50% of the confederates also included information about a past psychiatric hospitalization. Subsequent analyses found interviewers less friendly and less supportive of hiring the confederate when he added his psychiatric hospitalization” (Corrigan, Kerr, Knudsen, p. 180).
Organizations/Individuals Proposing the Definitions
There is a broad range of professional and organizational involvement in creating a definition of comorbidity of mental health substance use. Dating back to the 1800’s when mental health was thought to be categorized as only idiocy and insanity by the Census Bureau who were one of the first organizations to record and define mental illness. Then medical doctors along with psychologist utilize data provided by the National Commission on Mental Hygiene to assist with better understanding the stigma of mental illness. Many individuals play an important role in developing past and present definitions of comorbidity. Field research and surveys utilizing data, involving participants who were exhibiting symptoms that were had no definition and therefore no way of receiving treatment. There are many other organizations along with groups and individuals that assisted to define the comorbidity of mental illness and substance abuse.
The Diagnostic Statistical Manual of Mental Disorders (DSM) is considered the bible of the psychiatric field. There are also many psychiatry and mental health sources listed, American Psychiatric Association (APA) also remains one of the more prevalent sources of definitions to date. Journal of American Medical Association (JAMA).
Substance Abuse and Mental Health Service Administration (SAMSHA)
World Health Organization (WHO)
National Comorbidity Survey (NSC)
American Psychiatric Association (APA)
National Board for Certified Counselors (NBCC)
Association of Social Work Boards (ASWB)
History of the Problem
The need for classification of comorbidity and substance use in the United States was driven by the collection of statistical information for the census bureau a little over two hundred years ago. In 1880 the census bureau developed seven insanity descriptions including mania, melancholia, monomania, epilepsy and dementia (DSM-IV-TR, 1994). In 1917 American Psychiatric Association (APA) was developed then revised in 1932. One of the classification tools developed in 1900’s to define and diagnose mental illness, morbidity and mortality statistics, was the International Classification of Disease (ICD). The sixth edition (ICD-6) was the first international source to include mental disorders, offering (10) categories to diagnose psychoses and (7) categories for character, behavior and intelligence.
The development of the Diagnostic and statistical Manual of Mental Disorders (DSM) occurred in 1952 for the purpose of creating a professional consensus based on the standard knowledge of psychiatric disorders at the time. DSM-I included only three categories of disorders, DSM-II was developed then published in 1968 to continue establishing relationships between mental health professionals. DSM-II was more focused on children including Runaway Reaction and Group Delinquent Reaction (Scotti and Morris, 2000). The DSM-III was thought to be revolutionary because of its use of scientific evidence unlike the DSM-I and II DSM-III utilized the medical model approach which offered another point of view.
The Creation of the DSM-IV was derived from the history of the prior manuals written but they also utilized the research from what was called “steering committees” that also included several psychologist. Groups were developed to promote diversity and conduct field trials. These groups also utilized reports from extensive literature reviews of their own diagnoses including clinical research that was very important to clinical practice. The DSM-IV’s development did not however lack criticism and it was also accused of being biased towards biological explanations as opposed to clinical theories. Comorbidity, symptom overlap and other presentations were seen as threats to the reliability of data provided by other classification systems of the time. DSM-IV-TR ( was released in (2000), changing only factual errors and developing a more client centered language approach, used in affect to classify the disorder not the person (Blashfield, 1998, DSM-IV-TR, Scotti and Morris, 2000).
References
Abdulla, T., & T. B. (2011). Illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Mental Illness Stigma and Ethnocultural Beliefs, Values, and Norms: An Interview Review, 31, 934-948.
Blashfield, Scotti, & Morris. (2000). The Development of the DSM. Retrieved January 9, 2014, from http://kadi.myweb.uga.edu/The_Development_of_the DSM.html
Braga, R. J., Reynolds, G. P., & Siris, S. G. (2013). Anxiety comorbidity in schzophrenia. 210, 1-7. doi: 10.1016/j.psychres.2013.07.030
Building bridges: Co-occurring mental illness and addiction - Consumers and Service Providers, Policymakers, and Research in Dialogue Paperback – January 1, 2004.
(n.d.). Building Bridges: Co-Occurring Mental Illness and Addiction. Retrieved from http://www.amazon.com/Building-Bridges-Co-Occurring-Addiction-Policymakers/dp/B002LFW3I4
Busto, A., Souza, R. P., Lobo, D. S., Shaikh, S. A., Zawertailo, L. A., Busto, U. E., & Kennedy, J. L. (2010). Cocaine and amphetamine regulated transcript (CART) gene in the comorbidity of schizophrenia with alcohol use disorders and nicotine dependence. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 34(6), 834-836. doi: 10.1016/j.pnpbp.2010.03.030
Comorbidity of Phobic Disorders With Alcoholism in a Canadian Community Sample. (2001, October). Retrieved January 9, 2014, from https://ww1.cpa-apc.org/Publications/Archives/CJP/2001/October/comorbidity2.asp
Corrigan, P. W., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: Explanatory models and methods for change. Applied and Preventive Psychology, 11(3), 179-190. doi: 10.1016/j.appsy.2005.07.001
Dickey, B., & Hocine, A. (1996). Persons with Dual Diagnoses of Substance Abuse and Major Mental Illness: Their Excess Cost of Psychiatric Care. American Journal of Public Health, 86(7), 973-977.
Dziegielewski, S. F. (2002). DSM-IV-TR in action. New York:
Wiley.
EMCDDA backup download site for the 2013 European Drug Report. (n.d.). EMCDDA. doi: 10.2810/20027
Mueser, K. T., Bellack, A. S., & Blanchard, J. J. (1992). Comorbidity of schizophrenia and substance abuse: Implications for treatment. Journal of Consulting and Clinical Psychology, 60(6), 845-856. doi: 10.1037//0022-006X.60.6.845
Patel, K., & Wells, K. (2009). Applying Health Care Reform Principles to Mental Health and Sustance Abuse Services. JAMA, 302(13), 1463rd ser., 929-933.
Thomas Burns
Springfield College School of Human Services
According to the National Institute on Drug Addiction “comorbidity occurs when there are interactions between two disorders or illnesses and the interactions may happen simultaneously or sequentially in the same person” (2008, p.1). Europeans turn to the International Classification of Disease (ICD) in order to define comorbidity. This definition is reported through the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), who reports that comorbidity means “the presence or coexistence of additional diseases with the reference to an initial diagnoses or to the index condition …show more content…
that is being examined”(Baldacchino and Corkery, 2006).
There are several definitions reflected in the literature of peer reviewed journals and other academic sources. Researchers have indicated that we must first fully recognize drug addiction as a mental illness instead of a moral failing. Drug addiction and other mental illnesses are found to be more common among patients diagnosed with other illnesses, i.e. Hepatitis C and HIV. These secondary illnesses are usually direct results of individual’s drug use and their dependence.
National Institute on Drug Abuse, uses the term “mental illness chemical abusers” in place of comorbid, co-occurring and individuals dual diagnosed. They also assert that drug addiction should be defined as a mental illness, in the same categories as other mental disorders like depression, schizophrenia, anxiety and mania (NIDA, 2010 p.2). Mental illness disorders are made evident by the disorganization of an individual’s personality and emotions that have become seriously impaired.
Drug dependence and drug addiction begin to overlap one another in definition and meaning. Drug dependence however is not considered a mental illness, dependence is defined in the DSM-IV as when individuals build tolerance that requires higher doses and eventually ends with symptoms of withdrawals. Addiction is defined within the DSM-IV as a mental illness because of the compulsivity component, NIDA along with the DSM-IV believe that addiction changes elements of the brain that helps humans beings choose their hierarchy of needs. “Addiction changes the brain, disturbing the normal hierarchy of needs and desire, substituting new priorities connected to procuring and using drugs”(NIDA, 2010 p.2). Still many people continue to ask two very interesting questions about the comorbidity of addiction and mental illness. One question is, which illness evolved first? The mental illness or the addiction? Secondly which should be treated as the primary illness. These question has provoked a broad range of definitions from several different sources that attempt to answer those simple but difficult questions.
According to (NIDA) after surveying several adult individuals, they report becoming confused over the many years of living with the dual illnesses then not remembering which symptom appeared first (2008, p.3). NIDA does provides some the answers by referring to the DSM-IV which states “drug abuse and dependence has the ability to mimic the symptoms of other mental illnesses, such as crack cocaine and marijuana which increases the risk of psychosis” (APA 1994). Furthermore drug abuse and mental illnesses are thought to be caused by some overlapping factors such as genetics, high levels of stress and the experience of a traumatic event.
According to Canadian Journal of Psychiatry when describing comorbidity of alcoholism and mental illness, they believe that “the onset of phobic disorders precede the onset of alcohol use disorder”. Furthermore (CJP) underscores that comorbidity should be treated in an aggressive manner to treat the mental illness to prevent the onset of comorbidity with alcoholism. Moreover the Canadian Journal of Psychology (CJP) describes another alternative to questions by indicating that findings from research suggest that having multiple psychiatric disorders inhibits treatments which is thought to lead to poorer treatment outcome opposed to those with only one disorder (CJP, 2001, p.5 p.26). Another finding written in the (CJP) indicated that individuals with lifetime alcohol abuse or dependence are two to three times more likely of having mental illness disorders develop.
Terminology and definition of co-morbidity cannot be fully agreed upon between most of psychiatry, medical and substances abuse professionals from different parts of the world.
According to European Monitoring Centre for Drugs and Addiction ( EMCDDA) in reference to the relationship between substance use and mental health disorders, they define a general level of co-morbidity as “the coexistence of additional diseases and the reference to an initial diagnoses” (Baldacchino and Corkey,2006). The World Health Organization does not differ much in definition from most other organizational studies but they seem to individualize “mental health” and “substance use” in terms of referring to the co-occurrence of two “psychiatric disorders” not involving “psychoactive substance use” or the co-occurrence of two diagnosable substance disorders (WHO, …show more content…
2008).
Psychiatric co-morbidity does not imply that a relationship with substance use and mental health disorders exist, but they can however be present at the same time or can appear at different times in an individual’s lifetime (Frisher et al., 2009; Langas et al., 2011).
The EMCDDA, agrees with the DSM-IV that co-morbidity in general is difficult to diagnose because of the tendency of the drugs producing the same affects in individuals as mental illness, in addition difficulty also comes in assessing a time span of the two disorders.
Individuals diagnosed with mental health disorders are believed to more likely to use drugs to self-medicate which then goes on to trigger a latent mental health problem. What makes diagnosing even more difficult is that symptoms and their developing process must be diagnosed when they first appear. Lack of different methods for diagnosing and understanding comorbidity of mental illness and substance abuse slowed progress for many years. The most prevalent of methods used to define and diagnose remains in place today use a combination of the same international standard of instruments (i.e.) American Diagnostic Statistical Manual (DSM) and the International Classification of Disease (ICD) that were developed several years ago. Professionals who are defining or diagnosing individuals for comorbidity of mental health and substance abuse have a great influence on the individuals primary diagnoses based on which field they are working. Based on research from several sources it is still no clear evidence of which disorder is more prevalent in society, or if one causes the other. There is still no clear evidence which diagnoses shall be treated as the primary disorder but our methods has produced protocols of treatment that allow professionals to treat at least one at a time. Influence of treatment may still occur based on a providers personal or professional biases.
Social Values underlying Definitions
The different definitions of our social values today are reflected in the evidence of research gathered from mental health and psychiatric professionals and substance abuse professionals. These values are shown academic research and the data from thousands of written articles from United States and abroad. The theories and ideologies are formulated to be more client centered today. The advantage of defining the social values is to create better informed professionals with current and practical information. Ethical and highly skilled professionals are essential for continued effective clinically practice. The ideology and belief system of the majority of researchers promotes the importance recognizing a value system that embodies cultural diversity, individual self-worth, non-judgmental attitudes, respect and dignity.
There are values underlying our conceptualization of mental illness and substance abuse treatment. Professionals that are afforded the ability to participate in defining literature contribute to both positive and negative effects of our social values system. These are the individuals that emulate the importance of human relationships, social justice for the people they serve. Although most social values are usually meant to best serve the individuals diagnosed with co-occurring disorders, there can also be negative impacts resulting from the stigmas of diagnoses.
The social values underlying co-occurrence are endorsed by the mental health and the psychiatric industry. Being diagnosed with any mental illness that implies a defect of character which usually causes individuals to internalize and inter-personalize the label of mental illness and substance disorders. Social values are sometimes identified in combination through individuals that are gay, lesbian or based on their skin color can usually have moral imputation and egregious effects such as self-esteem and self-efficacy decrements.
Not everyone is affected negatively by professional or public opinion of people suffering from a mental illness or addiction. Many individuals become empowered by the belief that everyone has a negative perception of their illness and become advocates for themselves and others who are labeled as drug addicts and mentally ill. However, perception remains to be the driving force, sometimes based on the public value system of individual’s diagnoses. The criminal justice systems view, employers, housing market and even the level of care in our medical and mental health systems have all created policies and legislation driven by the definition of our American social values system.
Case Example of an employment problem by Farina (Farina & Felner, 1973). “A male confederate, posing as an unemployed worker, sought jobs at 32 businesses. The same work history was reported at each of job interviews except 50% of the confederates also included information about a past psychiatric hospitalization. Subsequent analyses found interviewers less friendly and less supportive of hiring the confederate when he added his psychiatric hospitalization” (Corrigan, Kerr, Knudsen, p. 180).
Organizations/Individuals Proposing the Definitions
There is a broad range of professional and organizational involvement in creating a definition of comorbidity of mental health substance use. Dating back to the 1800’s when mental health was thought to be categorized as only idiocy and insanity by the Census Bureau who were one of the first organizations to record and define mental illness. Then medical doctors along with psychologist utilize data provided by the National Commission on Mental Hygiene to assist with better understanding the stigma of mental illness. Many individuals play an important role in developing past and present definitions of comorbidity. Field research and surveys utilizing data, involving participants who were exhibiting symptoms that were had no definition and therefore no way of receiving treatment. There are many other organizations along with groups and individuals that assisted to define the comorbidity of mental illness and substance abuse.
The Diagnostic Statistical Manual of Mental Disorders (DSM) is considered the bible of the psychiatric field. There are also many psychiatry and mental health sources listed, American Psychiatric Association (APA) also remains one of the more prevalent sources of definitions to date. Journal of American Medical Association (JAMA).
Substance Abuse and Mental Health Service Administration (SAMSHA)
World Health Organization (WHO)
National Comorbidity Survey (NSC)
American Psychiatric Association (APA)
National Board for Certified Counselors (NBCC)
Association of Social Work Boards (ASWB)
History of the Problem
The need for classification of comorbidity and substance use in the United States was driven by the collection of statistical information for the census bureau a little over two hundred years ago. In 1880 the census bureau developed seven insanity descriptions including mania, melancholia, monomania, epilepsy and dementia (DSM-IV-TR, 1994). In 1917 American Psychiatric Association (APA) was developed then revised in 1932. One of the classification tools developed in 1900’s to define and diagnose mental illness, morbidity and mortality statistics, was the International Classification of Disease (ICD). The sixth edition (ICD-6) was the first international source to include mental disorders, offering (10) categories to diagnose psychoses and (7) categories for character, behavior and intelligence.
The development of the Diagnostic and statistical Manual of Mental Disorders (DSM) occurred in 1952 for the purpose of creating a professional consensus based on the standard knowledge of psychiatric disorders at the time. DSM-I included only three categories of disorders, DSM-II was developed then published in 1968 to continue establishing relationships between mental health professionals. DSM-II was more focused on children including Runaway Reaction and Group Delinquent Reaction (Scotti and Morris, 2000). The DSM-III was thought to be revolutionary because of its use of scientific evidence unlike the DSM-I and II DSM-III utilized the medical model approach which offered another point of view.
The Creation of the DSM-IV was derived from the history of the prior manuals written but they also utilized the research from what was called “steering committees” that also included several psychologist. Groups were developed to promote diversity and conduct field trials. These groups also utilized reports from extensive literature reviews of their own diagnoses including clinical research that was very important to clinical practice. The DSM-IV’s development did not however lack criticism and it was also accused of being biased towards biological explanations as opposed to clinical theories. Comorbidity, symptom overlap and other presentations were seen as threats to the reliability of data provided by other classification systems of the time. DSM-IV-TR ( was released in (2000), changing only factual errors and developing a more client centered language approach, used in affect to classify the disorder not the person (Blashfield, 1998, DSM-IV-TR, Scotti and Morris, 2000).
References
Abdulla, T., & T. B. (2011). Illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Mental Illness Stigma and Ethnocultural Beliefs, Values, and Norms: An Interview Review, 31, 934-948.
Blashfield, Scotti, & Morris. (2000). The Development of the DSM. Retrieved January 9, 2014, from http://kadi.myweb.uga.edu/The_Development_of_the DSM.html
Braga, R. J., Reynolds, G. P., & Siris, S. G. (2013). Anxiety comorbidity in schzophrenia. 210, 1-7. doi: 10.1016/j.psychres.2013.07.030
Building bridges: Co-occurring mental illness and addiction - Consumers and Service Providers, Policymakers, and Research in Dialogue Paperback – January 1, 2004.
(n.d.). Building Bridges: Co-Occurring Mental Illness and Addiction. Retrieved from http://www.amazon.com/Building-Bridges-Co-Occurring-Addiction-Policymakers/dp/B002LFW3I4
Busto, A., Souza, R. P., Lobo, D. S., Shaikh, S. A., Zawertailo, L. A., Busto, U. E., & Kennedy, J. L. (2010). Cocaine and amphetamine regulated transcript (CART) gene in the comorbidity of schizophrenia with alcohol use disorders and nicotine dependence. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 34(6), 834-836. doi: 10.1016/j.pnpbp.2010.03.030
Comorbidity of Phobic Disorders With Alcoholism in a Canadian Community Sample. (2001, October). Retrieved January 9, 2014, from https://ww1.cpa-apc.org/Publications/Archives/CJP/2001/October/comorbidity2.asp
Corrigan, P. W., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: Explanatory models and methods for change. Applied and Preventive Psychology, 11(3), 179-190. doi: 10.1016/j.appsy.2005.07.001
Dickey, B., & Hocine, A. (1996). Persons with Dual Diagnoses of Substance Abuse and Major Mental Illness: Their Excess Cost of Psychiatric Care. American Journal of Public Health, 86(7), 973-977.
Dziegielewski, S. F. (2002). DSM-IV-TR in action. New York:
Wiley.
EMCDDA backup download site for the 2013 European Drug Report. (n.d.). EMCDDA. doi: 10.2810/20027
Mueser, K. T., Bellack, A. S., & Blanchard, J. J. (1992). Comorbidity of schizophrenia and substance abuse: Implications for treatment. Journal of Consulting and Clinical Psychology, 60(6), 845-856. doi: 10.1037//0022-006X.60.6.845
Patel, K., & Wells, K. (2009). Applying Health Care Reform Principles to Mental Health and Sustance Abuse Services. JAMA, 302(13), 1463rd ser., 929-933.