It is common for people with substance use issues also to experience mental health conditions, and vice versa. However, the level of treatment engagement and retention among this population is limited due to various factors and barriers. Treatment approaches continue to be developed to help address these issues.
The importance of treatment engagement and retention
Substance use disorders (SUDs) affect around 48.4 million adults in the United States, with only 11.7 million (under a quarter) of these individuals utilizing professional SUD treatment. [1] Around half of people with an SUD develop a mental illness at some point in their lifetime, and vice versa. [2]
Impairments in functioning and well-being due to SUD and/or mental illness can include: [2]
- Impaired employment and academic performance
- Housing instability
- Physical illness
- Increased emergency room visits
- Increased likelihood of criminal activity and legal consequences, such as arrests or incarceration
- Increased risk of precipitating or experiencing interpersonal violence
These impairments are likely to be more severe among those with co-occurring SUD and mental illness, highlighting an increased need for intervention. However, concurrent SUD and mental illness can be complex and challenging to address, often leading to poorer treatment outcomes and more engagement issues, compared to those with either SUD or mental illness. [2][3]
As such, there is a need for comprehensive and integrated treatment approaches among those with a dual diagnosis, in order to effectively manage all aspects of the individualΓÇÖs well-being.
What the national study shows
Data compiled by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the 2023 National Survey on Drug Use and Health (NSDUH) show the frequency of professional treatment among people with either or both SUD and mental illness (MI). [1][4]
This data was collected among over 92,000 individuals aged 18 and over, in the United States. The prevalence of SUD among this population was 18.1%, and the prevalence of any MI was 23%. [1][4]
| Sought treatment for SUD | Sought treatment for MI | |
|---|---|---|
| Among the full study population | 4.6% | 22.3% |
| Among those with SUD | 14.4% | 37.0% |
These figures indicate that people are far more likely to seek mental health treatment than SUD treatment. This highlights, in particular, the prevalence of barriers to SUD treatment seeking. [4]
Barriers to engagement: Multi-level reality
There are many reasons why people experience barriers to treatment, ranging from personal reluctance to practical challenges. For example, common barriers to substance use and mental health treatments include: [5][6]
- A belief that professional help is not required 
- Limited services, providers, or availability of services, particularly relating to disparities between areas and communities
- Stigma around SUD and/or SUD treatments, causing people to feel unwilling to engage with services
- Confusion or unclear information about how to engage with services or which services are available
- Limited state-funded services and the inability to afford various services
- Limited services offering dual diagnosis treatment options, particularly among those with complex and severe mental health issues
Evidence-based strategies to improve engagement
The following aspects are found to be crucial to improved engagement and retention in SUD and mental health care: [6][7]
- Strong family and friend support networks
- Personal motivation
- Trusting therapeutic relationships
- Financial support
- Preventing parents from being separated from their children or providing childcare alongside treatments
- Flexibility in treatment delivery systems
- Population-specific treatments, such as women-only residential programs
- Empathetic and knowledgeable service providers
Evidence-based programs
Evidence-based treatment strategies to help address these aspects include: [6][7][8]
- Motivational interviewing and contingency management: Motivational interviewing (MI) and contingency management (CM) provide rewards and motivation for individuals in recovery. These can be important factors in improving treatment engagement and adherence, helping people explore their own values and goals.
- Community-based outreach programs: Outreach programs can provide care to individuals in rural areas or within communities that are less likely to have access to services. This approach can reduce significant barriers to treatment, helping to improve engagement and retention.
- Peer support: Peer support can include group meetings, education, and advocacy, led and provided by individuals who are also in recovery. This can help individuals develop trusting relationships with people who have lived similar experiences, who can provide care with an empathetic and non-judgmental approach.
- Family-focused interventions: This can include interventions such as family therapy, which can be of particular benefit to adolescents with concurrent SUD and mental health issues, providing education, support, and counseling for the family unit. Similarly, some organizations offer childcare alongside treatment or accommodation for parents and children while adults are engaged in residential treatment programs. This can help reduce reluctance to engage in treatment or drop-outs associated with family separation.
- Behavioral therapies: Interventions such as cognitive behavioral therapy (CBT) are found to be effective in both SUD and mental health treatment. They can be particularly beneficial for those with co-occurring conditions, as they address aspects of both concurrently. This integrated and structural approach can improve treatment engagement and medication adherence. 
Moving toward better engagement and outcomes
As research into the management of these conditions progresses, novel ideas and approaches continue to be developed to address the challenges faced in the treatment of co-occurring disorders. 
Additionally, further research is required in order to develop integrated treatment approaches that address specific co-occurring conditions, relating to the different types and severities of mental health conditions and specific substance use issues.