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August 2007 - Volume 3, No. 4
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Many clinicians challenged by patients with
addiction problems and serious mental illnessesTreating both disorders concurrently
may offer patient best results
by Tony P. George, MD, FRCPC
Professor of Psychiatry and Head,
Addiction Psychiatry Program, University of Toronto
Substance use disorders (SUDs) are common in Canada(1), but this is especially true in persons with comorbid serious mental illnesses (SMIs) such as schizophrenia, bipolar disorder, major depression and post-traumatic stress disorder.(2)
The lifetime prevalence of a SUD is about 50 per cent for these mental disorders(3), and the economic costs of this comorbidity are very high. This is not surprising given that mental health disorders and addictions are the top two causes of disability in the Western world.
It is also quite common for SUDs to go unrecognized by mental health providers. The fact that most mental health and addiction facilities are not able to adequately treat individuals with comorbid addiction and mental health disorders only adds to this problem.
In this brief article, individuals with comorbid SUDs and mental health disorders will be referred to as having concurrent disorders (CD).
Theories on concurrent disorders
Two leading theories of comorbid addiction and mental health disorders include: 1) the self-medication theory, which suggests that substance abuse arises in the context of an attempt to alleviate various aspects of the mental illness with the use of an addictive substance (e.g. cocaine for depression, alcohol for anxiety symptoms); and 2) the addiction vulnerability hypothesis, which posits that there is a common biological vulnerability that underlies both disorders.(4)
Experimental support for either has been difficult to gather in clinical studies, however most epidemiological evidence favours the second theory.
There is increasing evidence that substance abuse can alter the course of psychiatric illness. For example, the use of marijuana is associated with an earlier onset of psychosis in those diagnosed with schizophrenia, and bipolar illness tends to more commonly be of the rapid cycling or mixed type in those abusing alcohol or drugs.
Moreover, in most persons with SMIs, the onset of substance use typically comes after the onset of the mental disorder.(5) A notable exception appears to be tobacco use, which typically occurs prior to the onset of mental health disorders and is thought to be a marker associated with the presence of mental illness.(6)
Motivating patients to change
Engaging persons with CDs is often a significant challenge, as they frequently lack motivation to change addictive behaviours—common SUDs include alcohol, tobacco, marijuana, opioids, cocaine and other stimulants, and polysubstance use.
Determining motivational level using the Stage of Change model(7)—pre-contemplation (denial of the problem), contemplation (recognizing the problem), preparation (starting to consider a change), action (starting treatment) and maintenance (responding to treatment) is a useful first step.
Motivational enhancement therapies (MET) are a useful intervention for engaging and prompting behavioural change in these individuals. Early controlled studies have demonstrated the utility of MET in engaging both inpatients and outpatients with CD into initiation of drug abstinence.
Abstinence is not often realistic therefore reduced use accompanied by increased functional capacity is often a common goal, however defining outcomes using harm reduction approaches has been difficult.
Typically, most clinicians will first try to stabilize the concurrent psychiatric disorder before attempting addiction treatment, but this is often not practical. Treatment that addresses both disorders concurrently seems to have the best chance of engaging the patient and stabilizing both disorders.
Therapeutic models for CD treatment
The optimal approach to treating CD is one that combines pharmacological and behavioral therapies.
Behavioral therapies have received some recent attention in concurrent disorders and tend to weigh heavily on motivational and relapse-prevention intervention models. Findings from a recent study comparing integrated treatment of a group therapy program for concurrent bipolar disorder and substance abuse to a drug counseling only group revealed better overall drug treatment but not mental health symptom outcomes.(8)
Medications should be used aggressively to treat the comorbid mental health disorder. There is some evidence that comorbid substance abuse and schizophrenia can be concurrently treated with better outcomes using atypical versus typical antipsychotic drugs, and comorbid bipolar illness can be best managed with anti-convulsant mood-stabilizers as compared to lithium.
Patients with CD appear to experience frequent non-compliance with oral medications so consideration of depot formulations of medications (e.g. antipsychotics, naltrexone) is important. Use of oral adjunctive medications for addictions, such as methadone and buprenorphine (opioid dependence), naltrexone and acamprosate (alcohol dependence), and nicotine replacement therapies, bupropion, and varenicline (tobacco dependence), in persons with CD should be routinely considered for comorbid addiction treatment and appear to be well-tolerated and effective.
While most CD patients tend to be treated in mental health or addiction settings, the best outcomes are observed in settings which embrace an integrated treatment approach—where clinicians are trained to address both addictions and mental health disorders, and stage-based treatment is used.
Psychiatrists trained in addictions are uniquely qualified to lead such treatment, but sadly most psychiatry residency programs do not provide adequate training in SUDs or CDs.(9)
The adoption of evidence-based guidelines for the treatment of addictions in psychiatric patients recently published by the American Psychiatric Association(10) and the Substance Abuse and Mental Health Services Administration (SAMHSA)(11) in the United States, as well as Health Canada’s Best Practices in Concurrent Mental Health and Substance Use Disorders(2), holds considerable promise for improving the lives of CD patients. Moreover, research on the evaluation and treatment of CDs should be a priority for national funding agencies like the Canadian Institutes of Health Research (CIHR).
References
1. Adlaf, E.M., Begin, P., Sawka, E. (eds.), Canadian Addiction Survey (CAS). A national survey of Canadian’s use of alcohol and drugs: Prevalence of use and related harms. Ottawa: Canadian Centre for Substance Abuse (CCSA), 2005.
2. Rush, B., Best Practices: Concurrent Mental Health and Substance Use Disorders. Ottawa: Health Canada, 2002. P. 161.
3. Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., Goodwin, F.K., “Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study." J. Am. Med. Assoc., 1990. 264: p. 2511-2518.
4. Chambers, R.A., Krystal, J.H., Self, D.W., “A neurobiological basis for substance abuse comorbidity in schizophrenia." Biol. Psychiatry, 2001. 50: p. 71-83.
5. Kessler, R.C., “The Epidemiology of Dual Diagnosis." Biol. Psychiatry, 2004. 56: p. 730-737.
6. Kalman, D., Morrisette, S.B., George, T.P., “Co-morbidity of smoking with psychiatric and substance use disorders." Am. J. Addict., 2005. 14: p. 106-123.
7. Prochaska, J.O., DiClemente, C.C., “Stages and processes of self-change of smoking: Toward an integrative model of change." Journal of Consulting and Clinical Psychology, 1983. 51(3): p. 390-395.
8. Weiss, R.D., Griffin, M.L., Kolodziej, M.E., Greenfield, S.F., Najavits, L.M., Daley, D.C., Doreau, H.R., Hennen, J.A., “A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence." Am. J. Psychiatry, 2007. 164: p. 100-107.
9. Renner, J.A., Jr., Quinones, J., Wilson, A., “Training psychiatrists to diagnose and treat substance abuse disorders." Curr. Psychiatry Rep., 2005. 7: p. 352-359.
10. Kleber, H.D., Weiss, R.D., Anton, R.F., Jr., George, T.P., Greenfield, S.F., Kosten, T.R., O’Brien, C.P., Rounsaville, B.J., Strain, E.C., Ziedonis, D.M., Hennessey, G., Connery, H., “American Psychiatric Association. Clinical Practice Guidelines for the Treatment of Patients with Substance Use Disorders, 2nd edition." Am. J. Psychiatry, 2006. 163(8S): p. 5-82.
11. Anonymous, Co-Occurring Disorders: Integrated Dual Disorders Treatment - Information for Practitioners and Clinical Supervisors, Substance Abuse and Mental Health Services Administration (SAMHSA), Editors. 2003.
© Copyright 2007. Canadian Psychiatry Aujourd'hui. All rights reserved.
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