In this issue Urbanoski and colleagues report that substance use disorders frequently co-occur with psychiatric disorders in the population of patients seen by primary care providers. These findings complement those from the Epidemiologic Catchment Area surveys and from surveys of other populations worldwide and highlight the need to provide coordinated care to minimize problems resulting from insufficient or absent diagnosis-specific care.

Substance abuse increases impulsivity and decreases judgment of individuals prone to suicide, such as patients with bipolar disorder, schizophrenia, and attention-deficit hyperactivity disorder. Symptoms related to substance abuse complicate clinical presentation, and substance abuse is a risk factor for medical disorders such as HIV infection and cirrhosis. Persons with undetected psychiatric disorders may self-medicate with substances, although withdrawal states often worsen the condition that the substance was used to relieve.

Sadly, Urbanoski and colleagues also found that this group most in need of care has the greatest prevalence of unmet need and the lowest satisfaction with care provided. In fact, these patients often preferred self-management of their symptoms to the care that they received. Most caregivers think of cultural sensitivity as an understanding of how Native Americans, Hispanics, or African Americans conceive of illness etiology and seek care. Culture, however, has another dimension that these authors address—the need for diagnostic sensitivity to persons with a psychiatric disorder or co-occurring disorders.

We tend to recognize as treatable the patients whom we feel comfortable treating or with whom we identify. The different lifestyles of patients with co-occurring substance use and psychiatric disorders—and the frustrations often encountered in treating them—lead to a lack of vigilance in regard to this population and to a system characterized by treatment bias and little continuity of care. Co-occurring disorders stress care providers and demand continued enhancement of their clinical skills.

Urbanoski and colleagues point out that training in assessment, treatment, and referral of persons with co-occurring disorders is needed, along with sensitivity to the roles played by stigma and differing levels of disability and satisfaction with care. These authors emphasize the need for clinicians to develop treatment plans that are diagnostically specific and acceptable to those in greatest need of care. We must provide care in ways that are consistent with the ways that patients will seek care and in ways that will satisfy them—not in ways that we are most comfortable with. Good care requires cultural and diagnostic sensitivity, awareness of the role of severity and degree of functional impairment, and awareness of the role that stigma plays even among the most seasoned caregivers.