My son Aaron was 19 years old when he died. His death certificate says the cause of death was asphyxia. The actual cause was meth addiction and mental illness.
There was more to Aaron than that, just as there is more to so many like him. As a new report from the California Health Care Foundation shows, there is also much more we could be doing to help people who live with both mental illness and substance use disorder.
It’s not just a California problem or an American challenge. Throughout the world, far too many people have suffered because they were treated primarily for one diagnosis rather than for their intertwined conditions. Integrated care is hard to achieve, but a few states — including California — are pursuing promising approaches.
My son’s needs and struggles were not unique. Like a lot of teenagers, he was sad and looking for a place to belong, particularly when divorce broke up our family. He tried marijuana and said it made him feel better. Then, at 14, someone gave him meth.
My husband and I started by getting Aaron mental health care and followed up with substance use treatment. But as he began cycling through therapeutic programs, the juvenile justice system and the county psychiatric hospital, it became clear he needed much more. In the last two years of his life, as depression evolved into meth-induced psychosis, he was transformed into one of the many lost souls you see in homeless encampment. A person wrestling with more than one demon.
That’s when we encountered a deadly paradox at the heart of many health systems. Providers were prepared to treat Aaron’s psychosis or his chemical dependency — but it became a furious struggle to get them to treat both. Psychiatrists would treat only his anxiety and psychosis; substance use treatment facilities didn’t want to give him psychiatric medications. Coordination was scarce. We could see that he needed holistic care, but how?
A week before he died, Aaron was transferred from jail to a crisis residential mental health facility, where he was scheduled to see a psychiatrist and get his medication recalibrated. He arrived, without medication, after the psychiatrist had left for the day. He disappeared within the first 24 hours. A week later, on July 25, 2018, he was found dead near Highway 580 West in Richmond, Calif. He had hung himself.
At least 8.9 million American adults — including 500,000 Californians — have both mental illness and substance use disorder. Yet millions go untreated because of the structural separation between mental health and addiction services — each with their own professional training, data systems and privacy regulations — that makes it difficult to get coordinated, effective care.
Only 1 in 13 people with substance use disorder and mental illness receive treatment for both conditions. My family had health insurance and the financial means to get our son help. But even so, we ran into brick walls.
The California Health Care Foundation’s new study highlights the stories of Californians without the same resources who describe this struggle — one that often starts when patients first seek treatment and providers make a “primary diagnosis” that is almost always either mental illness or substance use disorder , but rarely both. This initial assessment dictates not only where people enter the health system, but also how they identify themselves — putting them at terrible risk of wholly inadequate care.
We saw this first hand with Aaron: Once he was diagnosed with depression, he saw himself as someone with a mental health condition, not as a user. He resisted being labeled an addict. He thought meth addicts were the scum of the earth, even when he became one. In this desperate fight, our fragmented health system swallowed up precious time, and for Aaron, time ran out.
It doesn’t have to be this way. For many people experiencing these challenges, truly coordinated care — across mental health, substance use and physical health systems — can bring real healing. In fact, this may be the most successful treatment available: care that actively treats the “whole person,” bringing all health providers together and connecting them to other supports like housing and transitions from residential treatment or incarceration.
Co-occurrence of substance use disorder and mental illness is not just a challenge here in the United States. The European Monitoring Center for Drugs and Drug Addiction cites the association of substance use disorder with serious mental illness as a “key issue for national and international drug policy,” and notes both the necessity and difficulty of concurrent diagnosis and treatment of both conditions.
Some states are working toward a solution, by moving to integrate types of care within their Medicaid programs. From 2016 to 2020, Washington state transitioned its Medicaid physical health, mental health and substance use disorder services into one integrated system. Early data show significant improvements in access to care for people with co-occurring mental illness and substance use disorder. California leaders are wisely pushing Medi-Cal, the state’s Medicaid system, in this direction, bringing better-integrated care to the program. An understanding that breaks down silos is also key: UCLA Medical School now requires psychiatry students to cross-train at a local addiction treatment center.
There is even more that nations and states should be doing, like simplifying the way care is paid for and helping families navigate these complex systems. We also need to demand real accountability, along with training and technical assistance, to make sure local health and social service providers are working together.
So many lives can be saved. So many families kept whole. We can help people like Aaron, and we must.
Katherine Haynes is a senior program officer at the California Health Care Foundation. She commissioned the foundation’s report “In Their Own Words: How Fragmented Care Harms People With Both Mental Illness and Substance Use Disorder.”