Patients See Gaps In Treating Both A Mental Health And Substance Use Disorder

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When Kat Lotti first started experimenting with drugs, she quickly realized she was different from her friends.

"I was an addict right off the bat," says Kat, who's now 27. "It wasn't like I just slipped into it doing it with friends. I used like an addict from day one. I didn't use for fun. It was as if I found a missing piece of my life."

For the past decade, Kat has struggled with what are called "co-occurring disorders" — meaning both a mental health and substance use disorder. She was diagnosed with anxiety in her teens and bipolar disorder in her early 20s. By then she was a heroin addict. "Self-medication has been a huge part of my downfall," Kat says.

Kat had been to a variety of both mental health and substance use treatment programs but she says no program ever tried to work on both of her conditions at the same time.

"There was never a focus on the psychological issues, which I always felt like they were totally missing the point," she says.

Kat Lotti struggles with what are called "co-occurring disorders," meaning both a mental health and substance use disorder. (Courtesy Rhonda Lotti)
Kat Lotti struggles with what are called "co-occurring disorders," meaning both a mental health and substance use disorder. (Courtesy Rhonda Lotti)

All of the substance use treatment programs Kat went to were based on the 12 steps of Alcoholics Anonymous. The "steps" are the basis of more than 80 percent of the substance use treatment in the United States and providers acknowledge they don't work for everyone. Kat says her treatment never connected her two conditions or tried to work on them simultaneously. She says she felt as if she'd be blamed if she said her treatment wasn't working.

"You can recite the steps at me all day but it's not going to make a difference if I still feel the same way I did before, and I still have the same problems and the same compulsions to fix these problems by any means necessary," Kat says.

A Treatment System Full Of Hurdles

Most estimates suggest that at least 60 percent of those seeking treatment for a substance use disorder also have a mental health condition. But it's not easy to untangle the two: Sometimes substances can induce mental health disorder symptoms — and it's tough to clearly diagnose a mental health condition while someone is actively using substances. Kat's mother, Rhonda Lotti, says even now her daughter has never had a comprehensive psychiatric evaluation and rarely has appropriate aftercare or follow-up that treatment centers promise to provide.

"Never a comprehensive psych eval because they're only focused on getting her off drugs. That's pretty much it," Rhonda says.

She says the treatment system is full of obstacles. The first hurdles, Rhonda says, are finding a bed and insurance coverage. If those are cleared, Rhonda learned that providers also have rules. Many times when seeking a bed at a dual diagnosis center, she had to first go to a hospital emergency room to be medically cleared and evaluated, a process that often takes several hours. Rhonda also says there were mental health treatment programs that would not accept Kat because she was actively using drugs — and substance use providers that would not admit her because of her mental health issues.

"Often times you're left to choose, OK, do we go just to straight substance use treatment or do we look more toward mental health?" Rhonda says. "Both are difficult to get into but if you're going straight substance use treatment then they're not addressing the mental health issues."

"[I]f this is the best mental health treatment and the best substance use treatment, wow — this country is in trouble."


In Massachusetts, different state agencies supervise treatment programs. The Department of Public Health oversees facilities treating those whose primary condition is a substance use disorder. The Department of Mental Health is in charge of programs where mental health is the patient's primary condition. State regulations do require substance use programs to assess clients for co-occurring disorders. Rhonda says Kat's case shows that more oversight is needed.

"We live here in Boston where we're supposed to have the best medical treatment in the country. And if this is the best mental health treatment and the best substance use treatment, wow — this country is in trouble," Rhonda says.

Facilities licensed in Massachusetts are required to provide "therapies, counseling and education which conform to accepted standards of care." But providers don't always agree on those standards and have vastly different opinions about things such as whether to use medication or what type of therapy or social supports might work. Providers say it's particularly tricky when dealing with complex psychiatric issues.

"We live in a society that wants simple answers to really complicated questions," says Dr. Mark Albanese of the Cambridge Health Alliance. "So people say to me, 'Does trauma predate the addiction or vice versa?' and my answer is ' — yes.' It really is both." Albanese goes as far as saying that most addiction is self-medicating for a mental health issue like trauma. But he says substance use itself can cause or exacerbate mental health issues.

"Once you're caught up in that substance use life you are vulnerable to ongoing traumatic episodes. So, yes, maybe the original trauma came first but then you put yourself in a position of being at risk of further being victimized," Albanese says.

Connecting Mental Health And Substance Use

To get at some of the mental health issues causing the problem, Dr. Albanese says a patient has to start to connect the dots between their substance use and their mental health. One of his patients is 75-year-old Richard, who didn't want his last name used in this story because of the stigma of substance use and mental health issues. He has been working with Dr. Albanese for about five years and he says it took him decades to realize why he was using drugs.

"I had to connect them up together — the trauma led me to the symptoms and the symptoms led me to the drugs," Richard says.

Richard was a psychology professor, running a daycare center and going to school. He says he was under a lot of pressure and started hiding his drinking from his family. He realized he had a problem when he was in his 30s. Even though he stopped drinking for years, when pressure hit again, Richard started using heroin.

"I was saying to myself, 'I'm just doing this to keep myself going, probably stress. I'll wait until June when I won't be teaching, I'll be done with school and I'll stop,' " Richard remembers. "But in June, the drinking went up. That's when I knew I had a problem. And I guess that time later when I took the heroin it was clear that I had a substance use disorder."

Further complicating things for Richard was his reluctance to admit he had a mental health issue. He says for most of the people he knows who are in recovery, it's easier to admit to having a drug problem than having a mental health issue.

"Most of the people that I know in the program, if you say to them, 'You know, we have a mental health issue,' [they'll say] 'I don't have a mental health issue. I've got addiction. I am not mentally ill and I don't appreciate you saying that,' " Richard says laughing.

For the past five years, Richard has been on the drug buprenorphine to reduce his cravings for opioids and he takes psychiatric medications. He also regularly sees Dr. Albanese and attends group counseling sessions and 12-step meetings. Today, Richard says, his treatment works.

But like Kat, Richard agrees that effective treatment can be hard to find. Even last year's report from the U.S. surgeon general says "the field of addiction treatment has not been adopting evidence- and measurement-based practices at the same rate as other medical fields." A study of addiction treatment in Massachusetts released a few months ago recommends that the state do more to integrate mental health and substance use treatment and help patients assess the quality of treatment.

Albanese, who's worked in treatment for decades, says it can seem discouraging, but scientific advances like new medicines and the urgency to save people's lives are helping to improve treatment.

"The thing I have to keep in mind is that in 2017 versus 1997, it's a much better environment. More people have gotten the message. We have a ways to go, but I have more hope than I did 30 years ago," Albanese says.

But Rhonda Lotti isn't sure if her daughter will survive long enough to find the right care.

"I don't know that she's ready to really commit to a life of sobriety," Rhonda says. "But then I worry that, even if she was ready, is there treatment out there to help her to choose that."

Recently, Kat went missing for a week, but she eventually called Rhonda, who expects that she will again help her daughter find treatment.

Rhonda says she has to remain hopeful — in 2011, she lost her then-19-year-old daughter, Mariah, to a heroin overdose.

This segment aired on May 8, 2017.


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Deborah Becker Host/Reporter
Deborah Becker is a senior correspondent and host at WBUR. Her reporting focuses on mental health, criminal justice and education.



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