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Young adults experiencing homelessness are disproportionately affected by mental health disorders and substance use issues.
May 22, 2024
When individuals are diagnosed with both severe emotional disturbances (SED) or serious mental illness (SMI) alongside substance use disorders (SUD), the challenges they face are compounded. These co-occurring disorders create a vicious cycle, amplifying the severity of each condition and making recovery far more complex and demanding.
For young people specifically, the presence of co-occurring disorders correlates strongly with alarming negative life outcomes. For instance, there is a markedly increased risk of suicidal ideation and attempts among these individuals. This heightened risk points to the critical need for early intervention and comprehensive treatment strategies that address both the mental health and substance use components simultaneously. These young adults are less likely to graduate high school on time, which can significantly impact their future employment opportunities and overall life trajectory. Early pregnancy is another concerning outcome, reflecting how untreated or poorly managed co-occurring disorders can derail the lives of young individuals, leading to further social and economic challenges.
The prevalence of co-occurring disorders in the juvenile justice system is striking. Although data is limited, existing estimates indicate that young adults in contact with the justice system exhibit significantly higher rates of SED and SUD compared to the general young adult population. Approximately 62 percent of individuals in this system meet the criteria for at least one mental disorder, with a substantial 61 percent of these individuals also having a co-occurring SUD. This fact clarifies the critical intersection where mental health, substance use, and the criminal justice system collide, often resulting in a cycle of incarceration if not properly addressed through tailored therapeutic interventions.
Young adults experiencing homelessness are disproportionately affected by mental health disorders and substance use issues. Conditions such as anxiety, panic disorder, major depression, bipolar disorder, schizophrenia, and posttraumatic stress disorder are far more prevalent among homeless young adults compared to their stably housed peers.
To effectively address the needs of these at-risk populations, it is essential to adopt an integrated approach to treatment. This involves not only managing the immediate symptoms of mental health and substance use disorders but also addressing the broader social determinants of health, such as housing stability, educational support, and criminal justice involvement. By doing so, we can break the cycle of co-occurring disorders and their associated negative outcomes, paving the way for more resilient, healthier futures for these young individuals.
Approximately 17 percent of young adults group access mental health services in specialty settings, which include inpatient, residential, and outpatient mental health facilities. Another 18 percent receive services in non-specialty settings, such as outpatient primary health care, educational institutions, child welfare agencies, and juvenile justice systems. Notably, of those who receive mental health services in non-specialty settings, a significant 85 percent are served within school environments. This highlights the critical role that educational institutions play in providing mental health support to young people.
When addressing the needs of young adults with severe emotional disturbances (SED) or serious mental illness (SMI) who also struggle with substance misuse or substance use disorders (SUD), the pathways to treatment are often fragmented. These individuals may receive care within the mental health system, the substance use treatment system, or both.
The lack of an integrated treatment approach means that these young individuals do not receive the seamless, continuous care necessary for effective treatment and recovery. Each transition between systems or providers can disrupt the therapeutic process, leading to gaps in care and communication. This disjointed care model undermines the efficacy of treatment, as different providers may not coordinate well or share critical information, making it difficult to develop and maintain a coherent, comprehensive treatment plan.
For young adults with co-occurring disorders, the stakes are particularly high. The interplay between mental health issues and substance misuse can exacerbate each condition, making recovery more challenging. Without a unified treatment approach that addresses both mental health and substance use simultaneously, these individuals face a higher risk of poor outcomes, including relapse, worsening mental health symptoms, and failure to achieve lasting recovery.
Addressing this issue requires a shift toward integrated care models that combine mental health and substance use treatment within a cohesive framework. By making space for collaboration between mental health professionals, substance use counselors, and other relevant service providers, we can ensure that young adults receive consistent, comprehensive care.
Young adults grappling with co-occurring severe emotional disturbances (SED) or serious mental illness (SMI) and substance use disorders (SUD) require a person-centered approach to treatment. Effective treatment must encompass a broad range of services, including psychosocial interventions, family behavioral therapy, medication, proactive outreach, and specialized applications that assist in interventions and symptom tracking. Integrated treatment models that simultaneously address both SED/SMI and substance misuse yield better long-term outcomes by providing a cohesive framework for recovery.
However, accessing integrated services remains a significant challenge for many young adults with co-occurring disorders. Several barriers contribute to this difficulty. Many young individuals lack access to sufficient health insurance, which is crucial for covering the comprehensive care they need. Care for these individuals is often disjointed, especially for those in foster care, juvenile justice systems, residential settings, or experiencing homelessness. This fragmentation can lead to inconsistent treatment and poor outcomes. There is a notable gap in the education and training of mental health and substance use professionals, which impedes the delivery of integrated care.
Despite these challenges, progress has been made in certain areas. The integration of effective, evidence-based behavioral health services in primary care and school settings is expanding, recognizing that these are common access points for young adults. The increased availability of telehealth services has improved access to treatment, particularly for those in remote or underserved areas. Efforts to enhance educational and training programs for professionals are also underway, aiming to better equip them to handle co-occurring disorders. Continued research and implementation of systematic, integrated approaches are critical for improving the availability and accessibility of services for this vulnerable population. By focusing on comprehensive, coordinated care that addresses the needs of young adults with co-occurring SED/SMI and SUD, we can pave the way for more effective treatments and better long-term outcomes.
Cognitive Behavioral Therapy (CBT) is a short-term, goal-oriented psychotherapy that plays a crucial role in treating individuals with co-occurring severe emotional disturbances (SED) or serious mental illness (SMI) and substance use disorders (SUD). This therapeutic approach helps individuals identify and understand their current problems, challenges, and experiences, aiming to change their patterns of thinking or behavior. By using CBT, clinicians can simultaneously prioritize treatment goals for both SED/SMI and co-occurring SUD, maintaining a consistent therapeutic approach across these disorders. Previous systematic reviews have consistently shown that CBT yields favorable results, particularly for young adults dealing with anxiety or depression. Integrated Cognitive Behavioral Therapy (I-CBT) builds on the principles of traditional CBT to specifically address SUD and co-occurring conditions such as suicidal ideation or post-traumatic stress disorder (PTSD). I-CBT focuses on the relationship between these co-occurring disorders, offering flexibility to address them either concurrently or separately within treatment sessions.
In practice, I-CBT combines components of traditional CBT sessions that are effective for standalone disorders, applying them in an integrated manner. For example, problem-solving skills that are beneficial for both SUD and trauma can be taught in a unified way, making the treatment process more efficient and cohesive. This flexibility ensures that therapy can be adapted to the individual's presenting problems and treatment goals, enhancing the overall effectiveness of the intervention. A review of five studies highlighted the efficacy of CBT and I-CBT in outpatient settings, such as community mental health centers and school-based health centers. These studies included clients with co-occurring substance misuse or SUD and mental disorders, including PTSD, major depressive disorder (MDD), and suicidal ideation. The results were promising: all studies reported positive, significant outcomes, with the I-CBT study—being the only randomized-controlled trial—playing a pivotal role in determining the overall effectiveness of CBT practices.
The findings from these studies demonstrated that CBT is associated with reductions in substance use and improvements in depressive symptoms. CBT can be effectively combined with other therapeutic approaches, such as motivational enhancement therapy (MET) and pharmacotherapy, to enhance treatment outcomes further. This comprehensive approach ensures that individuals with co-occurring disorders receive a multifaceted and adaptable treatment strategy, leading to better long-term recovery and improved quality of life.
These therapies recognize that an individual’s symptom management, retention in treatment, and overall treatment response are influenced by individual-level factors, such as genetics and personal motivation, and family-level factors, such as the home environment and interpersonal relationships. Among the various approaches within family-based therapy, Multidimensional Family Therapy (MDFT) stands out as a structured, manualized method specifically targeting young adults' substance misuse and substance use disorders (SUD) alongside concurrent substance use and co-occurring mental health and behavioral issues.
The effectiveness of MDFT has been demonstrated through several randomized controlled trials (RCTs). Three RCTs have shown MDFT’s efficacy in treating young adults with varying severity and types of SUD, even in the absence of co-occurring mental illnesses. Another RCT confirmed its effectiveness for young adults with mental disorders. A systematic review of five RCTs focused on MDFT’s impact on young adults with substance misuse or SUD alone found it to be slightly more effective in reducing substance use compared to other treatments, indicating its potential superiority over standard or no treatment. Specifically, MDFT showed positive effects on reducing non-opioid drug use and concurrent substance use at both 6- and 12-month follow-ups, although the differences were relatively small.
A broader review examined MDFT’s effectiveness in addressing not only substance misuse but also related issues such as delinquency, externalizing and internalizing psychopathology, and family dysfunction among adolescents with substance misuse and/or antisocial behavior, though not necessarily diagnosed with severe emotional disturbances. MDFT integrates principles from developmental psychology, psychopathology, the ecological perspective, and family therapy.
Despite generally small effect sizes, this comprehensive approach has produced significant improvements across these domains. Adolescents with severe substance misuse and disruptive behavior disorders benefited more from MDFT than those with less severe conditions. A separate study conducted in outpatient settings with young adults who have co-occurring mental disorders and substance misuse or SUD demonstrated significant reductions in both substance use and adverse mental health outcomes. These findings demonstrate the value of MDFT in providing an integrative, family-centered treatment approach that addresses the multifaceted needs of young adults struggling with substance use and co-occurring mental health issues. By engaging the family unit and leveraging developmental and ecological perspectives, MDFT creates a supportive environment conducive to lasting recovery and improved overall well-being.
Pharmacotherapy also plays a critical role in the treatment of young adults with severe emotional disturbances (SED), serious mental illness (SMI), and substance use disorders (SUD). This approach involves using medications approved by the Food and Drug Administration (FDA) to address these conditions. For SED and SMI, several medications are FDA-approved, specifically for young adults. Certain medications are approved to treat SUDs, such as nicotine replacement therapies and medications for opioid use disorder, tailored to the individual's age.
The FDA approval process ensures that medications are safe and effective for specific conditions. However, it is important to note that not all medications used to treat children have been thoroughly studied in pediatric populations. This gap often leads to reliance on expert consensus and practice guidelines, such as those from the American Academy of Child & Adolescent Psychiatry (AACAP), to inform treatment decisions. Typically, medications are first studied in adults to gain FDA approval, and the absence of pediatric studies may reflect a lack of specific research rather than an inherent unsuitability for young adults.
For specific mood and anxiety disorders, several medications have FDA approval for use in both young adults. For example, fluoxetine and escitalopram are approved for depression; duloxetine is approved for generalized anxiety disorder; and medications like fluoxetine, clomipramine, fluvoxamine, and sertraline are approved for obsessive-compulsive disorder (OCD).
Guidance for treating young adults with these medications often comes from AACAP’s clinical practice guidelines and practice parameters. The FDA has approved the use of buprenorphine for individuals aged 16 and older and methadone and naltrexone for those 18 and older, supporting improved health outcomes for individuals with opioid use disorder. Addressing SED/SMI and SUD concurrently is important, as treating one condition does not necessarily alleviate the other. Medications can provide significant symptom relief, allowing individuals to utilize additional recovery strategies effectively. The most effective behavioral health approach often involves a combination of pharmacotherapy and psychotherapy. Counseling and specialized psychotherapies, such as Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET), aim to change behaviors, thoughts, and emotions and improve individuals' understanding of their situations.
MET and CBT (MET/CBT) provide a comprehensive psychotherapy framework. MET sessions might focus on the consequences of substance use, reasons for change, and goal setting, while CBT sessions emphasize learning refusal skills, identifying social supports, and managing emotions. This combined MET/CBT approach can be used alone or alongside pharmacotherapy to treat young adults with co-occurring disorders, providing a well-rounded and effective treatment strategy. The integration of these therapies ensures a well-balanced approach to recovery, addressing co-occurring mental health and substance use disorders.
