This commentary expands on McCloskey et al.’s [1] chapter, “Comprehensive Care for People with Behavioral Addictions and Co-Occurring Disorders,” by describing the proposed comprehensive-collaborative care model (CCCM) and distinguishing it from current collaborative and integrated care approaches. Comprehensive-collaborative care is defined here as an interdisciplinary, patient-inclusive model in which medical, behavioral health, and psychosocial providers actively share assessment, treatment planning, and outcome monitoring responsibility for a unified clinical presentation, in this case, as applied to behavioral addictions (BAs) and co-occurring disorders (CODs). We strongly emphasize that the CCCM currently is a conceptual framework requiring empirical validation along with significant multi-stakeholder advocacy and accreditation advocacy. The proposed CCCM may appear as a composite of current addiction treatment models, particularly integrated and coordinated care. While the CCCM model integrates these models, it shifts the focus of development to begin in the education of all healthcare professionals to see one another as parts of the whole, not separate parts. In this commentary, we clarify nomenclature and definition of BAs, present a case example applying the CCCM, and propose a pedagogical shift where education is not simply focused on one discipline but is geared toward recognizing and utilizing multidisciplinary approaches by all providers to assist clients in achieving their identified outcomes.

Addiction treatments have historically focused on chemical dependency as the primary marker of addictive pathology [2–4]. Chemical dependency or SUD is defined as excessive use of any substance(s) that result in tolerance, withdrawal; psychological and/or physical, significant problems in core life areas, difficulty stopping/staying stopped, multiple unsuccessful attempts to cut down or stop, and ongoing use despite negative consequences [5–7]. Some examples of well-known SUD include alcohol use disorder (AUD), opiate use disorder (OUD), and cannabis use disorder (CUD) [5].

While the literature varies in its use of BAs and behavioral process addictions (BPAs), this commentary uses the terms interchangeably to reflect shared core addiction criteria. Behavioral addiction is defined as compulsive engagement in and excessive attachment to a person, object, or behavior [2,7,8]. This pattern is characterized by (a) a persistent inability to stop the behavior, even when it leads to negative consequences, (b) an increasing need for the behavior-tolerance, with psychological and/or physical discomfort without the behavior, (c) a termed withdrawal, and (d) a progressive loss of control over the behavior itself, particularly when there are other psychiatric comorbidities [2,7,8]. However, these BA are not as readily found as formal diagnoses due to the ongoing lack of consensus in solidifying a formal set of criteria for all BPA; therefore, impacting the recognition of multiple BA as addictions.

Currently, the only accepted and classified BA include gambling use disorder (GUD), and IGD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) [5]; the former in the substance-related and addictive disorders section, and the latter in the section identified as “considered for further study” [5]. The International Classification of Diseases (ICD-11) of the World Health Organization (WHO) [9], categorizes both GUD and IGD as behavioral addictions. However, lack of agreement continues to exist on what differentiates a behavior from being a hyper focused activity versus an addiction [2,4,7]. For example, there are internet and social-media related behaviors, like IGD, in that they are concerning online activities, and display similar criteria proposed by researchers matching that of GUD, but are not labeled as addictions [2,7,10]. Obsessive scrolling, impulsive and compulsive posting and/or focus on perfecting one’s appearance through filtering excessive pictures, compulsive checking for feedback, displaying criteria for social medical addiction [11], internet addiction, internet-based pornography addiction and online shopping, represent predominant internet-related behaviors [3,8]. These BPAs are supported by neurobiological research suggesting activation of similar brain sections [12,13]. There is additional support for the inclusion of these proposed BAs based on other research with comparable results to IGD, GUD, and SUD [14,15].

Research has also prompted some experts to re-evaluate the potential to reclassify additional behaviors, including binge eating disorder (BED) and non-suicidal self-injury (NSSI). Currently, BED is categorized in the Feeding and Eating Disorders section of the DSM-5-TR [5]. In the ICD [9], BED is categorized in Chapter 06, “Mental, behavioral, or neurodevelopmental disorders; Feeding or Eating disorders.” NSSI is classified as a condition, not a formal diagnosis in both the DSM-5-TR and the ICD and focuses on the compulsive act without suicide intent [5,9]. There is growing evidence supporting the addictive nature of these behaviors, drawing on Griffiths’ [2] components model of BAs, and SUD criteria outlined in the DSM-5-TR [5,16,17]. For example, Mestre-Bach and Potenza [15] highlight multiple biogenetic studies linking specific brain reward system processes involved in SUD, and non-substance-related addictive processes including GUD, that co-exist with those with BED. If similar physiological, psychological, and behavioral criteria are used to include GUD and are also being observed in those with BED, then this provides an avenue for inclusion of BED in classification systems as a BA and has positive implications for BED treatment protocols as a BA [15,17].

The WHO [9] and DSM-5-TR [5] provide the gold standard as to what constitutes a mental health disorder for the world and the United States, respectively. Therefore, the limited inclusion of BPAs from these diagnostic manuals prevents focus on education to medical and behavioral health providers. In addition, this limited inclusion results in a lack of evidence-based and standardized treatment protocols, and inadequate support for rigorous research and reimbursement from third party payers [8,18,19]. This leads to BAs more often than not being explored by most healthcare professionals during patient evaluation, as available and reliable assessments, which are not often included in standard assessment protocols, despite the existence of such assessments [8,18,19]. All these implications hinder individuals from receiving treatment for BPA as most are not covered by insurance. Therefore, optimal care by all healthcare providers regarding BAs and other COD is most likely being limited as when BAs are not covered by insurance to the same degree as SUD, there lacks training focus for health care providers to treat BAs, resulting in patients not being fully assessed in these areas [6,18,20].

Current research estimates a global prevalence of 11.1% for BA, or 913 million people who meet criteria, based on the work of Griffiths [2], for at least one behavioral addiction [21]. This number may be much higher as it does not account for people's understanding of what a BA is, lack of inquiring about a BA by providers, and patients’ openness during assessments [22–24]. One may suggest, as with SUD and other COD statistics, factors impacting reporting accuracy include providers assuming SUD are primarily what are thought of regarding addictive behaviors, low use of BA assessments by front line workers, individual shame to self-report, and many not seeking treatment [21–23,25]. Despite a lack of agreement on the criteria for all BPAs, Griffiths’ [2] work had ignited many scholars’ focus on achieving his goal with the aim of providing people with optimal care for BA and COD [18,26].

To provide a general recap, Griffiths’ original work (2005) identified six components of addictive behavior to highlight similar pathology to SUD and to differentiate an addiction from a hobby, stating "the difference between an excessive healthy enthusiasm and an addiction is that healthy enthusiasms add to life whereas addictions take away from it” [2]. These six components are: (a) Salience: physical, cognitive and psychological obsession with an activity; (b) Mood modification: purposeful behavior to change a mood; (c) Tolerance: the need for increased engagement in a behavior to obtain desired outcomes; (d) Withdrawal: discomfort when not engaged in the behavior; (e) Conflict: problems in core life areas; and (f) Relapse: the potential to return to the addictive behavior after a period of cessation [2]. Much of the scholarly debate centers on the premise that BA’s do not have physical withdrawal symptoms compared to SUD [4,12]. Additional research exhibits established biological similarities between BA and SUD [12,13]. For instance, functional neuroimaging and molecular studies indicate that similar dopaminergic surges occur in the midbrain's ventral tegmental area (VTA) and substantia nigra, which lead to the mesolimbic reward area. In addition, such activators cause neuroplastic changes in the prefrontal cortex, resulting in diminished executive control and heightened impulsivity, both in SUD and BA [12,13]. As there are chemical and biological-based processes occurring, we propose that they are therefore physical, as in SUD.

Substance-related and addictive disorders, including BAs, are further complicated by the high rate of co-occurring disorders COD [4,14]. Kotyuk et al.’s [27] research estimated that between one-third and one-half of individuals presenting with an addictive disorder also have a COD. Research indicates that individuals with BPAs are significantly more likely to present with concurrent SUD, mood, anxiety, or personality disorders [14,27,28]. This brings to the forefront the importance of collaboration among providers to treat BAs and all COD, both within a biopsychosocial framework and in accordance with the proposed CCCM [29]. Research suggests providers are still struggling with collaboration aspects due to multiple limitations, including treatment philosophies, time constraints, lack of third-party reimbursements, and a general siloed approach to care [1,3,20,28–30].

The following is a recap of the example of the case utilized in the original chapter to highlight what the proposed CCCM would look like. Jim, the identified patient referenced in the book, represents a plethora of individuals who require healthcare from a system, as it currently is. These individuals often present with multiple healthcare issues, requiring multiple providers and resulting in confusing and often suboptimal care [31,32]. The following emphasizes the current system, which has multiple negative implications for a client seeking care for a BA and other COD, whether SUD, medical, or a combination thereof. The case then turns into a demonstration of the highlights of CCCM.

Jim was receiving care from multiple providers for an array of healthcare issues. Jim, a veteran, saw his primary care provider (PCP) and a psychiatrist at his local VA clinic. In addition, he attended a weekly PTSD group at the VA of his own volition, led by a group counselor who was also a retired veteran. Having PTSD from his time in active combat, Jim was hesitant to share his problems with the VA staff and therefore engaged in outpatient (OP) therapy with a licensed professional counselor. During his initial assessment with his OP counselor, Jim said he could not stop drinking and was using alcohol and going to the casino at night to avoid sleep due to severe flashbacks. He also said he attended Alcoholics Anonymous, though infrequently, and continued to drink due to an additional COD, chronic knee pain. The counselor asked Jim if he would be willing to answer additional questions and complete additional forms to help the counselor understand how to help him better, and Jim agreed. Jim completed the Alcohol Disorders Identification Test (ADUIT) [33], the Behavioral Addiction Questionnaire (BAQ) [34].

The counselor went over the results in depth with Jim, so he understood them and asked if he had discussed any of his addiction or mental health concerns with his PCP or psychiatrist at the VA or in his VA PTSD group. Jim stated, “my PCP never asked me about my gambling, and I wasn’t completely honest about my drinking,” sharing he feared judgment and would not receive treatment he may need for his knee injury. Jim stated that the psychiatrist suggested counseling for his flashbacks, and Jim followed up with an outside clinician. Jim also thought the PCP’s main job was to address his knee but did acknowledge that both the PCP and psychiatrist suggested attending the PTSD group and AA might help cut down his drinking.

With additional discussions in therapy, Jim agreed to sign releases so all treating providers could speak with one another. In addition, the counselor included Jim in a phone call to the PCP to discuss Jim’s test results and concerns, and the PCP set up an appointment. Both the counselor and the PCP explained to Jim that there were options, including providing medication for his BA, AUD, and flashbacks. After Jim was prescribed medication, he thanked the counselor, who took the opportunity to suggest to him the importance of comprehensive collaborative care between him and all his providers on a regular basis. Jim, originally hesitant and fearful, agreed to this addition to his treatment. The counselor educated Jim about how the proposed approach could catch potentially missed implications that could impact his care. In conclusion, a monthly online meeting was set up bringing together the client, the OP counselor, the psychiatrist, PCP, PTSD group counselor from the VA, and a member of Jim’s personal support group to discuss what was working, what was not, and to allow the client to ask questions, share concerns and to hear options from multiple providers working as an interdisciplinary team to increase the client’s desired outcomes.

The case study highlights the benefits of comprehensive-collaborative care in the following ways: the inclusion of the client and all members of the treatment team provides increased accountability for seeking the best outcomes for the patient [30,32]. Perhaps most important is that many clients struggling with BAs and COD who may experience longer waiting times to receive care can result in not feeling important, increased irritability with having to repeat their stories and symptomology repeatedly to multiple providers, and eventually making the decision to stop seeking help, resulting in decreased treatment engagement [22,35,36]. If the healthcare system can decrease the time a client waits to obtain effective care, it might pave the way to increased positive outcomes, including decreased symptomatology and increased patient commitment, as they will more likely feel important and heard, and overall positive outcomes.

We propose that the CCCM may also help reduce the likelihood of relapses, as the client has a stronger support team, all of whom know what the others are doing [20]. The sharing of information between providers helps avoid conflicts and overlaps in treatments, particularly adverse medication effects [31,37]. Having a collaborative team in place makes each service provider aware of the broader range of resources available to the client, and what services may be necessary, which are neither systematically nor consistently provided [36–38]. Having a communication plan in place avoids the hassles often associated with communication between service providers, which hinder timely client care. Most importantly, the CCCM offers the client a safety net, allowing for client empowerment and motivation for desired outcomes as they are always linked to one or more of their treatment teams.

Primary care providers have a unique advantage in identifying early markers of BAs during routine screenings [19,34]. The presentation of unexplained symptoms: social withdrawal, sleep deprivation, elevated mood symptoms, problems with school, work, and financial concerns, while often attributed to general stress, may represent emerging symptoms of a behavioral addiction, which could be screened by the primary care provider [19,28,31,34]. Utilizing these clinical encounters with primary care providers could be useful for early detection, prevention, and the initiation of comprehensive collaborative care.

Often, healthcare providers do not use BPA screening tools during assessments with both adults and children, which can delay the identification of potential BAs and further complicate treatment due to extended time without recommended practices [28,31,34]. Typical addiction-related assessments used in PCP offices are disproportionately geared toward chemical substances and frequently omit potential BA, except GUD, as it is both a classified and known addiction [19,28,34]. Currently, multiple screening tools are available for most BAs [18,28]. For specific tools, please review our chapter in Equipping the interdisciplinary workforce to treat Substance Use Disorders and Behavioral Health [40]. In addition, the development of more reliable and inclusive screening tools may allow for the identification of multiple BA and COD [18,28,39].

Implicit bias continues to affect the medical perception of non-substance addictions. Research by Rundle et al. [32] identified that, after alcohol and opiate use disorders, disease and moral addiction models stigmatize behavioral addictions more than socially based models, such as the biopsychosocial (BPS) model [29]. Stigma often acts as an impediment to honest patient disclosure [23,25,41,42]. The use of a non-judgmental, evidence-based approach, informed by collaboration amongst all providers with an emphasis on the patient as the most vital component, can help increase trust [23,25,32,41]. Ricciutti’s [42] research supported addressing curricula development in counseling programs related to BPAs and SUD as they discussed findings that clinicians used “negative and derogatory” towards clients with BPAs. Again, research supports and encourages additional education on BPAs and SUD where topics on biases are incorporated [42,43]. The CCCM, combined with the BPS, framework [29], provides an approach aimed at strengthening the therapeutic alliance which can improve diagnostic accuracy.

When a provider fails to screen for BPAs, they can lean towards practicing non-optimal health care [5,18,23,25] potentially ignoring a substantial portion of the patient’s behavior that may be undermining the efficacy of other psychiatric treatments, such as multiple BA, SUD, and other COD [8]. This lends support to the CCCM, as collaborating with multiple providers can decrease missed care opportunities [8,19]. For example, the stress and cortisol elevation resulting from a compulsive shopping, or gambling debt can completely negate the stabilization efforts of pharmacological treatments for generalized anxiety disorder, major depressive disorder, and other co-morbid disorders [13,14,19]. Therefore, while attempting to stabilize a client/patient, ignoring the potential BA could decrease the likelihood of desired outcomes [13,19].

Treatment protocols can be addressed among providers from a CCCM. All providers play a part in how clients learn about, identify needs, engage, and be accountable to themselves, their support groups, and their treatment teams [20,39]. The CCCM proposes providers as part of the support group, not simply disconnected, because from most frameworks, patients issues are not disconnected. Current treatment protocols for those with BAs and COD include medication-assisted therapies (MAT), cognitive behavioral therapy (CBT), motivational interviewing (MI), and contingency management (CM) to address treatment concerns and allow patients to develop a variety of coping skills necessary for long-term recovery [1,18]. MAT continues to suggest multiple uses for addictions, classified and not, and other COD.

Despite the use of pharmacological treatments for SUD and the existence of research to support similar MAT for BA [10,18], many primary care providers lack knowledge in this area and/or are unwilling to provide MAT to people with BAs [7,20]. Pharmacological management represents a significant frontier in treatment, as it is constantly changing [10,18]. Opioid antagonists, such as Naltrexone, have demonstrated efficacy in decreasing cravings and the corresponding reinforcement associated with GUD and other BAs [10]. Unlike SUD, where total abstinence is often the primary endpoint, many BAs involve behaviors which are integral to modern life, such as eating, using the internet, exercising, shopping, and engaging in sexual relations. Abstinence oriented recovery may not be sufficient for treating all BAs [7,18]. There is a need for enhanced professional competency in non-abstinence-based recovery goals and best practices across multiple health care disciplines to better support the CCCM [18,20,44].

Additionally, digital health innovations, including mHealth platforms for real-time monitoring, allow for clinical oversight that was previously impractical in outpatient settings [39]. Neuromodulation and mindfulness, based on dialectical behavior therapy (DBT), are treatments now recommended for BA [7,18]. These advances suggest that the evolution of addiction medicine and treatment also requires all providers to engage in advocacy to support progress across education, patient care, insurance, and government regulations [32,39].

Table 1 outlines the primary structural differences between (a) Coordinated Care, (b) Integrated Care and (c) the Comprehensive Collaborative Care Model, across five domains.

The proposed CCCM is currently a theoretical framework and requires additional empirical studies to further develop and support its implementation. Due to ethical concerns, qualitative designs for behavioral and medical healthcare students receiving CCCM-based curricula and activities are one option to identify philosophical differences compared to those receiving education as usual [45]. In addition, ex post facto designs could be used to identify outcomes among patients who received treatment as usual versus interventions based in the CCCM, separately and combined, for both BAs and COD. Lastly, comparative effectiveness research or observational studies could be applied to a variety of types of treatment programs, based on either integrated or collaborative, and the CCCM to compare outcomes on a range of variables. The starting point for the CCCM model must be the educational process across all health care programs, to begin the pedagogical shift from a siloed approach to CCCM in modern health care.

Educators of all healthcare providers are well-positioned to create both a paradigm and a pedagogical shift in educational programs from a siloed approach to a CCCM approach. Far too often, provider education focuses solely on their general and specialty requirements. However, we propose that under the CCCM, all providers recognize the importance of other providers and how to best collaborate with them within the health care system. This is essential to enabling a paradigm shift that will change how providers see one another and how they develop working relationships during their education. For example, having mental health providers provide training to medical students, and vice versa, would introduce the CCCM early enough in future providers’ education that a CCCM approach would become not merely suggested but the norm. The inclusion of post-degree training for and by multidisciplinary healthcare providers would be ideal to reinforce the importance of this approach. This approach would suggest that graduates from all healthcare backgrounds view their work as part of what is necessary to treat the whole person [41].

Additionally, the model proposes that collaboration among providers and patients be imperative. Research reveals those who feel valued and prioritized are more likely to remain in and engage in treatment [23,41]. Placing the patient at the center of the collaborative care team would increase the likelihood of identifying problems which otherwise may have been missed by a siloed approach. Moreover, such collaboration may advance professional understanding of medical and behavioral pathologies. For example, increased collaboration may lead to more consensus upon the nature of appropriate diagnostic classification of, and treatment protocols for behavioral addiction.

Research identifies increasing BPA rates between 30.7% for smartphone addiction, 21% for food addiction, 15.1% for social media addiction, and 10.6% for internet addiction between 2013 and 2022 [14,21,28]. To add to this concern, research suggests approximately 15% of the American population, 50.8 million Americans, reported co-occurring disorders, suggesting a doubling of reported and diagnosed cases since 2019 [4,14,41]. Mental health reporting increased from 11.5% to 14.1% between 2013 and 2022, while 21.2 million adults had a co-occurring mental illness and substance use disorder in 2024 [28].

As cases of BAs and other COD, including SUD, continue to rise, we propose the need to promote increased optimal care. A shift toward the CCCM encourages collaboration among providers and patients to develop treatment plans that enhance care efficiency through a philosophical model while integrating it with an evidence-based framework, the BPS [1,29]. Supporting comprehensive collaborative care will require interdisciplinary advocacy to allow both research and pedagogical changes in academic healthcare settings to encourage interdisciplinary partnerships among providers.

Behavioral addictions are complex conditions requiring the same clinical rigor and therapeutic resources as SUD. Current diagnostic divides are the byproduct of outdated addiction science, and acknowledging this evolution is the first step toward modernizing care. Currently, medical and mental health systems are not well-suited to a collaborative approach. Looking ahead, our proposed comprehensive-collaborative care model would enable interdisciplinary teams to work as a unit, built on pedagogical changes designed to reduce siloed approaches. These teams would have the benefit of viewing presenting behavioral addictions and any additional co-occurring psychiatric comorbidities as unified clinical cases with the individual as the nexus. This proposed philosophical approach aims to enable the healthcare community to provide more comprehensive-collaborative care that could increase the likelihood of positive outcomes.