By: Douglas M.
Ziedonis, Ed. Day, Erin L. O’Hea, Jonathan Krejci, Jeffrey A. Berman
and David Smelson
The co-morbidity of a concurrent substance use disorder and a non-substance major psychiatric disorder is quite common. Yet there is very little data available to inform the clinician as to what treatment(s) might be best for this particular group of patients with this particular set of substance abuse plus non-substance psychiatric co-morbidity.
The co-morbidity of a concurrent substance use disorder and a non-substance major psychiatric disorder is quite common. Yet there is very little data available to inform the clinician as to what treatment(s) might be best for this particular group of patients with this particular set of substance abuse plus non-substance psychiatric co-morbidity.
In general, the limited research available, consensus
recommendations and clinical experiences all suggest that integrated treatment, i.e. treatment by
the same group of providers that addresses both the substance misuse and the other
major mental
illness is most effective. However, there are exceptions to this rule and
providers must be flexible and offer a combination of services regarding what works best in
treating the mental disorder plus what works best in the treatment of the
specific substance abuse disorder. While on the surface this appears to be
logical and pragmatic, this kind of reasoning does not always work. For example, there is
some evidence that lithium is less effective in people with bipolar
disorder complicated by
substance abuse than it is in bipolar disorder alone. Furthermore, some pharmacological
agents used
to treat some psychiatric disorders have an increased liability for abuse and
dependency, suggesting greater caution in using these interventions when
substance abuse is a comorbid issue.
The most efficacious treatment approach is probably integrated
multi-modal treatment which involves the same group of caregivers providing treatment to
both the mental
illness and the substance misuse disorder. These integrated treatments draw
from and utilize a wide variety of psychosocial interventions that are combined with
more specific
psychopharmacological strategies that address the specific psychiatric disorder
and some of the craving and withdrawal symptoms of the substance misuse. However,
much more research needs
to be done in this important and common area of practice.
Introduction
Co-occurring mental illness and addiction is common and worsens patient clinical course, treatment compliance, and outcomes (McLellan et al., 1998; SAMSHA, 2003; Westermeyer et al., 2004). Co-occurring disorders are so common that the phenomenon has become the expectation in addiction, mental health, and medical treatment settings. Recent research and clinical experience has improved the system, programme, and clinical interventions that can help these individuals.
Despite being common, the co-occurrence of mental illness and substance use
presents a diagnostic and treatment challenge for clinicians and treatment
services. The term
‘dual diagnosis’ is often used to describe this problem, although it lacks
precision in describing a very heterogeneous problem. The pattern of
co-morbidity may vary
between co-morbid mood, anxiety and personality disorders in patients
attending substance misuse treatment services, and co-morbid alcohol, cannabis
and cocaine
misuse in patients accessing general psychiatric services (Abou-Saleh, 2004).
Therefore, we prefer the term co-occurring disorder as opposed to dual diagnosis.
The high rate of co-occurring severe mental health and substance use problems has
been increasingly recognized in the international
research literature over the past 20 years (Maslin, 2003). The National Co-morbidity Study (NCS) and the
Epidemiological Catchment Area (ECA) Study both demonstrated that co-occurring mental
illness and addiction are very
common in the general population, criminal justice system, and treatment system. In the
NCS, individuals
with alcohol dependence had high rates of clinical depression during
their lifetime (24% major depression and 11% dysthymia for men and 49% major
depression and 21%
dysthymia for women), and individuals with bipolar disorder had high rates of
alcohol (61%) and
other drug (41%) dependence. High rates of personality disorders have also been
reported in patients with substance use disorders, particularly antisocial,
narcissistic, and borderline personality disorders (Ross et
al., 1988; SAMSHA, 2003; Ziedonis et
al., 1994). Personality disorders in substance
abuse treatment settings have a poorer response to treatment and a
greater risk of suicide (American Psychiatric Association, 1994; SAMSHA, 2003).
Finally, tobacco
dependence is the most common substance of abuse in the United States and often
occurs among
individuals being treated for other forms of addiction and mental health
problems (Ziedonis & Williams, 2003).
Despite methodological problems such as differences in
sampling methods, populations and diagnostic systems, these
co-morbidity trends appear to be consistent across treatment settings in the
USA (Mueser et al., 2000), the UK (Graham et
al., 2001; Menezes et
al., 1996), Germany (Krausz et
al., 1996), and Australia (Fowler et
al., 1998).
Individuals with co-occurring mental illness and addiction
have more cravings, withdrawal symptoms, cognitive impairment, depressive
symptoms, relapses, and poorer responses to traditional treatments compared to
individuals with addictive disorders alone (Carol et
al., 2001; Smelson et
al., 2001, 2002a, 2002b 2003). These
individuals often have wide
fluctuations in mental status, increased suicide risk, poorer medication compliance, increased hospitalizations and
emergency room visits, and increased HIV rates, hepatitis C rates, physical
trauma, and
other co-existing medical morbidity/mortality.
Finally, individuals with dual diagnosis have higher rates of homelessness, greater
chances of perpetrating violence and being the victim of traumatic events, and greater
incidence of illegal
activities compared to individuals with mental illness or addiction alone (SAMHSA, 2003).
Summary and conclusions
Psychiatric and substance use disorders commonly co-occur and require the clinician to have additional knowledge and skills in assessing and treating both types of disorders. There are many subtypes of co-occurring mental illness and addiction disorders based on the different types of disorders, the severity of each disorder, and the motivation to address either disorder.
Due
to the chronic and often long-standing nature of co-occurring disorders,
precise and detailed history taking is critical to accurate diagnoses. The use of collaborative sources of
information cannot be overemphasized.
Previously clinicians thought it appropriate to withhold treatment for the psychiatric symptoms until a patient was abstinent for a long period of time. However, now treatment is often initiated much earlier. While each disorder impacts the other, the clinician is often faced with the need to treat withdrawal, intoxication, affective, psychotic and cognitive symptoms without a clear understanding of the exact cause and effect relationships of the presenting symptoms.
Previously clinicians thought it appropriate to withhold treatment for the psychiatric symptoms until a patient was abstinent for a long period of time. However, now treatment is often initiated much earlier. While each disorder impacts the other, the clinician is often faced with the need to treat withdrawal, intoxication, affective, psychotic and cognitive symptoms without a clear understanding of the exact cause and effect relationships of the presenting symptoms.
More
research is needed to study and develop improved treatment approaches for the
wide range of co-occurring disorder subtypes in all treatment settings. The use of more than one
psychosocial therapy could facilitate better outcomes. For example, the alcoholic with major depression may require
motivational enhancement therapy, 12 step facilitation and relapse prevention for the substance abuse or dependence
and cognitive behavioural, interpersonal, brief psychodynamic or supportive
psychotherapy for the depression. Regular reassessment of the patient will
facilitate a more precise diagnosis and better targeted interventions.
References
Peter
Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in
Psychiatry, Cambridge University Press 2008.
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