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COPYRIGHT 2003 American Counseling Association
In a sample of 700 drug users, 64% evidenced comorbidity (i.e., coexisting substance use and psychiatric disorders). Robust relationships between the presence of comorbidity and increased levels of risk behavior, such as needle sharing and trading sex for money, were revealed.
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Comorbidity (i.e., the coexistence of substance abuse and mental health disorders in the same individual--also known as dual diagnosis) has received increased attention in the mental health and substance abuse literature since it was first documented on a large scale in the late 1980s and early 1990s (e.g., Heizer & Pryzbeck, 1988; Regier et al., 1990). This increased attention is driven by the realization that most individuals who seek counseling for mental health symptoms are revealed to have substance abuse symptoms on closer assessment, and most individuals seeking counseling for substance abuse evidence symptoms of other psychiatric distress (Brems & Johnson, 1997; Kessler, Crum, Warner, & Nelson, 1997; Kessler et al., 1996; Wu, Kouzis, & Leaf, 1999). In fact, mental health and substance abuse treatment professionals are slowly recognizing that the singular existence of either substance abuse or mental health symptoms has become the exception rather than the rule among substance abuse and mental health clientele (Kessler, 1995). Comorbidity presents challenges to treatment providers, not only because individuals with multiple diagnoses require different treatment approaches but also because such individuals engage in increased risk-taking behaviors (cf. Brems & Johnson, 1997).
Risks associated with comorbidity have been addressed in recent research for the general population, mental health treatment samples, and substance abuse treatment samples. Findings indicate that clients with comorbidity tend to have fewer and less adequate relationships and social support networks (Laudet, Magura, Vogel, & Knight, 2000; Wu et al., 1999). They also often have unstable housing, employment, and income histories (Drake & Mueser, 2000; Hipwell, Singh, & Clark, 2000; Wu et al., 1999) and tend to be younger and less educated (Cuffel, 1996; Mueser, Bennett, & Kushner, 1995). These clients are more likely to have criminal or other legal problems (Clark, Ricketts, & McHugo, 1999; Hipwell et al., 2000), and they tend to have poorer overall functional skills (Hoff & Rosenheck, 1998; King, Gaines, Lambert, Summerfelt, & Bickman, 2000), such as more problems with family relationships, more restricted social networks, and difficulty in maintaining employment. Given these challenges, clients with comorbidity often have more difficulty gaining access to treatment, have a poorer course of treatment, have less successful treatment outcomes, and incur more treatment costs than clients with only mental health or substance abuse symptoms (e.g., Drake & Mueser, 2000; Hipwell et al., 2000; Hoff & Rosenheck, 1998, 1999; Wu et al., 1999).
Another group of individuals, for whom high levels of risk-taking behaviors have been documented in recent years, are drug users not currently in treatment. For example, this population reports high levels of risky drug-taking behaviors, including sharing of injection equipment (Fisher, Cagle, Queen, & Hosmer, 1994; Singer, Himmelgreen, Dushay, & Weeks, 1998), and sexually risky behaviors, such as trading sex for money or drugs and having unprotected sex (Fenaughty & Fisher, 1998). This group of individuals experiences high rates of depression (Johnson, Fisher, Estrada, & Stevens, 1995; Johnson, Fisher, Fenaughty, & Theno, 1998) and general psychopathology (Johnson, Brems, & Fisher, 1996). Relative to physical disorders, drug users not currently in treatment have a high prevalence of HIV/AIDS (Montoya & Atkinson, 1996); hepatitis A (HAV), B (HBV), and C (HCV; Fisher et al., 1997; Johnson et al., 1998; Kleyn, Schwebke, & Holmes, 1993; Kuhrt-Hunstiger & Fisher, 1994; Orr, Fenaughty, & Fisher, 1995); STDs (e.g., chlamydia, gonorrhea, herpes, syphilis; Orr et al., 1995; Paschane, Fisher, Cagle, & Fenaughty, 1998; Williams et al., 1996); and anemia (Montoya, Richard, Ataabadi, & Atkinson, 1998).
An issue that remains to be explored is whether there is a relationship between drug use and coexisting mental health symptoms (i.e., comorbidity) that attenuates risk behavior among out-of-treatment drug users. Given research findings to date about clients with comorbidity and about drug users not in treatment, we hypothesized that individuals with both factors will report higher levels of risk behaviors than a comparable group of individuals with only one of these problems. To test this hypothesis, we explored levels of risk-taking behaviors among drug users not currently in treatment with coexisting psychopathology and compared them with those of drug users not currently in treatment without coexisting psychopathology.
Method
Participants
Two samples of participants were recruited from separate Anchorage-based projects funded by the National Institute on Drug Abuse (NIDA). The first sample (n = 191) was drawn from participants in the Anchorage site of the Cooperative Agreement on AIDS...
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