Behavioral therapies for co-occurring substance use and mood disorders.

There has been marked progress in recent years in the development of effective behavioral therapies for substance use disorders and in the largely independent development of behavioral therapies for mood disorders. Until recently, however, there were few well-specified behavioral approaches that incorporated an integrated approach for individuals in whom these disorders co-occur. The emerging literature on the efficacy of several types of behavioral therapy for engaging individuals with co-occurring mood and substance use disorders in treatment, reducing substance use and affective symptoms, enhancing adherence, and preventing disengagement and relapse is reviewed, followed by discussion of the challenges likely to be met in integrating these behavioral approaches into clinical practice.     

Reliability of dual diagnosis. Substance dependence and psychiatric disorders.

The Structured Clinical Interview for DSM-III-R was used to examine the effects of the co-occurrence of psychiatric and substance dependence disorders on diagnostic reliability. The test-retest reliability over a 1-week period was studied in groups of: a) individuals with current substance abuse diagnoses (N = 97), b) individuals with past, but not current, drug histories (N = 146), and c) individuals without substance abuse diagnoses (N = 356; primarily psychiatric patients). A measurement of reliability (Kappa coefficients) was estimated for four general psychiatric categories (psychotic, mood, anxiety, and eating disorders), along with specific most-frequent diagnoses in each category (schizophrenia, major depression, panic disorders, and bulimia nervosa, respectively). Past use and non-drug-use groups were similar in their generally reliable reporting of current and past psychiatric disorders. However, current mood and psychotic disorders were less reliably diagnosed in the group with current substance use disorders.     

Co-occurring mental and substance use disorders: the neurobiological effects of chronic stress

The high rate of co-occurrence of substance use disorders and other psychiatric disorders is well established. The population of people with co-occurring disorders is heterogeneous, and the prevalence of comorbidity differs by diagnostic group. One of the overarching issues in the area of comorbidity is the nature of the connection between psychiatric disorders and substance use disorders. The rapid development of technical advances in the neurosciences has led to a better understanding of the molecular biology, neurotransmitter systems, and neural circuitry involved in mental illness and substance use disorders. The authors discuss the neurobiological interface between substance use disorders and other psychiatric disorders with an emphasis on emerging data concerning four psychiatric disorders that commonly co-occur with substance use disorders: depression/mood disorders, posttraumatic stress disorder, attention deficit hyperactivity disorder, and schizophrenia. Better understanding of the connection between substance use disorders and psychiatric disorders could have a profound effect on prevention and treatment.     

Review of treatment recommendations for persons with a co-occurring affective or anxiety and substance use disorder

OBJECTIVE: The authors review and evaluate the literature and guidelines on care for individuals with a co-occurring affective or anxiety disorder and substance use disorder. METHODS: MEDLINE and PsycINFO computerized searches of the English language literature were conducted for the period 1990-2002. These articles were supplemented with searches of the Cochrane Database of Systematic Reviews (1990 to 2002) and with articles that were sent to the authors by experts in the field to review. Bibliographies of selected papers were hand searched for additional articles. From these searches a total of 219 articles were found, of which 127 were selected for review. RESULTS AND DISCUSSION: The literature shows that, over the past several decades, treatment for co-occurring disorders has undergone a broad shift in approach, from treating substance abuse before providing mental health care to providing simultaneous treatment for each disorder, regardless of the status of the comorbid condition. Many treatment recommendations are supported by a broad consensus. However, despite this broad agreement, recommendations are often not specific enough to guide clinical care. Most recommendations with specificity are for acute pharmacotherapy, but even specific recommendations lag behind current clinical practice. Although the use of psychotropic medication for mental illness is encouraged, experts disagree as to whether it is necessary to wait for abstinence before beginning pharmacotherapy. In addition, most diagnosis-specific guidelines are silent as to whether the specific treatment recommendation applies to co-occurring disorders. Finally, empirical evidence is lacking for most recommendations. The authors conclude that the mental health and substance abuse treatment fields need to consider its research priorities and how to address the multitude of potential combinations of disorders.     

Assessment and treatment of mood disorders in the context of substance abuse

Recognition and management of mood symptoms in individuals using alcohol and/or other drugs represent a daily challenge for clinicians in both inpatient and outpatient treatment settings. Diagnosis of underlying mood disorders in the context of ongoing substance abuse requires careful collection of psychiatric history, and is often critical for optimal treatment planning and outcomes. Failure to recognize major depression or bipolar disorders in these patients can result in increased relapse rates, recurrence of mood episodes, and elevated risk of completed suicide. Over the past decade, epidemiologic research has clarified the prevalence of comorbid mood disorders in substance-dependent individuals, overturning previous assumptions that depression in these patients is simply an artifact of intoxication and/or withdrawal, therefore requiring no treatment. However, our understanding of the bidirectional relationships between mood and substance use disorders in terms of their course(s) of illness and prognoses remains limited. Like-wise, strikingly little treatment research exists to guide clinical decision making in co-occurring mood and substance use disorders, given their high prevalence and public health burden. Here we overview what is known and the salient gaps of knowledge where data might enhance diagnosis and treatment of these complicated patients.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Bipolar disorder and substance abuse.

Substance use disorders are overrepresented in individuals with bipolar and bipolar spectrum disorders. Although awareness of this phenomenon has increased over the past 20 years, few empirically based treatment strategies have been developed for this challenging patient population. This review examines the relationship between bipolar and substance use disorders and treatment options that have been studied in this patient population. First, we examine the high prevalence rates of substance use disorders in individuals diagnosed with bipolar disorder, the common problems associated with establishing a bipolar disorder diagnosis in individuals who abuse substances, the possible explanations for the frequent coexistence of bipolar and substance use disorders, and the negative effect of substance abuse on the course of and treatment outcomes for bipolar disorder. The review then focuses on treatment approaches for this patient population, including integrated group therapy for co-occurring bipolar and substance use disorders and pharmacotherapies that target both disorders. Finally, we present suggestions for medications that might be tested for their efficacy in treating both disorders in specific subgroups of patients with bipolar and substance use disorders.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Suicide in adolescents with disruptive disorders.

OBJECTIVE: To determine the psychiatric risk factors for suicide in adolescents with disruptive disorders. METHOD: Fifty-nine adolescent suicide completers and 18 community controls, both having a probable or definite current DSM-III diagnosis of disruptive disorders, were compared. RESULTS: Adolescents with disruptive disorders who committed suicide had higher rates of current substance abuse, past suicide attempt, family history of substance abuse, and family history of mood disorder than disruptive community controls. CONCLUSIONS: Disruptive adolescents appear to be at risk for completed suicide when comorbid substance abuse and past history of suicide attempt are present. The risk increases if the adolescents have a past history of physical abuse and if they have parents with substance abuse and mood disorders. Clinicians should be aware of these risk factors and implement active interventions to prevent suicide. Treatment should focus on treating not only the adolescents, but also their family members. The findings of this study also highlight the need for future research in the prevention of suicide in adolescents with disruptive disorders and comorbid substance abuse.     

Temporal sequencing of lifetime mood disorders in relation to comorbid anxiety and substance use disorders

Background: Little is known about the temporal sequencing of psychiatric disorders. The aim of this study was to obtain insight into patterns of co-occurrence of DSM-III-R mood disorders in relation to anxiety and substance use disorders, their temporal sequencing and the sociodemographic and long-term vulnerability predictors of this temporal sequencing. Methods: Data are from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a psychiatric epidemiological study in a representative sample of 7,076 adults aged 18–64. Results: Of those who had ever experienced a mood disorder, 46 % of males and 57 % of females had a history of anxiety disorders, and 43 % and 15 % of substance use disorders. Mood disorders were associated with all anxiety and substance use disorders, except with alcohol abuse among males. In the majority of anxiety-comorbid cases, the mood disorder arose after the anxiety disorder; the pattern for substance use-comorbid disorders was more variable. Deviation from the usual sequence of major depression and anxiety disorders was more often seen among females, subjects with a higher educational level, subjects who experienced childhood parental divorce, and subjects who experienced childhood emotional neglect. Conclusions: When comorbid with anxiety disorders, mood disorders clearly tend to be secondary. Few of the studied demographic factors, familial vulnerability factors and childhood life events predict the sequencing of mood disorders in relation to other disorders. Received: 20 September 2001 / Accepted: 29 July 2002 Correspondence to R. de Graaf     

Three-year outcomes of long-term patients with co-occurring bipolar and substance use disorders.

Little is known about the long-term outcomes of patients in the public mental health system who are disabled by co-occurring bipolar and substance use disorders. This article reports on the 3-year course of 51 patients with co-occurring bipolar and substance use disorders in the New Hampshire Dual Diagnosis Study. Participants received integrated dual disorders treatments in the state mental health system and were independently assessed with standardized measures at baseline and every 6 months for 3 years. Though psychiatric symptoms improved only modestly, participants improved steadily in terms of remission from substance abuse (61% in full remission at 3 years); they also achieved greater independent living (average 239 days in third year), competitive employment (49% in third year), regular social contacts with nonsubstance abusers (46% at 3 years), and quality of life (56% satisfied with life at 3 years). Different domains of outcome were only weakly related to each other. Long-term, disabled patients with co-occurring bipolar and substance use disorders have potential for remission from substance abuse and substantial improvements in functioning and quality of life.     

Mood disorders: review of current diagnostic systems

In their sections on mood disorders, both ICD-10 and DSM-IV represent considerable advances on ICD-9 in drawing affective disorders together in one section, distinguishing bipolar disorder from unipolar, including dysthymia and using clear definitions. Problems with ICD-10 include complexity, use of different clinical and research definitions, emphasis on single versus recurrent episodes and the lack of some clinically useful subtypes. DSM-IV is less complex but assigns separate unjustified categories of medical and substance-induced mood disorders, and fails to code its useful qualifiers. Both classifications preserve categories for psychotic depression and melancholia/somatic syndrome, which are better coded in ICD-10. The severity distinctions could usefully be extended to a milder category of minor depression. It is also recommended that the two classifications be brought together, with small differences in definitions ironed out and a single set used both clinically and for research, the simpler DSM-IV organisation, the omission of the categorisations of single versus recurrent and mood disorder due to general medical or substance abuse disorders, and the inclusion of coding for some subtypes such as seasonal and postpartum.     

Risk of suicide in mood disorders

Suicide is commonly associated with mood disorders. Risk factors for suicide in mood disorders can be organized according to whether their effect is on the threshold or diathesis for suicidal acts or whether they serve mainly as triggers or precipitants of suicidal acts. Predisposition to suicidal behavior or diathesis is a key element that helps to differentiate patients who are at high risk versus those at lower risk. The objective severity of mood disorders does not identify depressed patients at high risk for suicide attempt. There is a lack of agreement over the suicide risk associated with characteristics of depression such as psychotic features, agitation, or anxiety, or mixed mood states as part of bipolar disorder. Risk factors affecting the diathesis for suicidal behavior include family history of suicide, low cerebrospinal fluid 5-hydroxyindolacetic acid, alcohol and/or substance abuse, cluster B personality disorder, high past impulsivity and aggression, chronic physical illness particularly involving the brain, marital isolation, parental loss before age 11, childhood history of physical and sexual abuse, hopelessness, and not living with a child under age 18. Most common precipitants of suicidal acts in mood disorders include interpersonal losses or conflicts, financial trouble, and job problems. Identification of high risk patients and effective treatment are required for suicide prevention to reduce morbidity and mortality in affective disorders.     

Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders

OBJECTIVE: Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. METHODS: A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. RESULTS: A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the usual-care group. For substance use outcomes, no effect was found. The meta-analysis demonstrated small but statistically significant overall improvement in women's trauma and mental health symptoms in the intervention relative to the usual-care comparison condition. Analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement, whereas the delivery of numerous core services yielded less improvement relative to the comparison group. A few person-level characteristics were associated with increases or decreases in the intervention effect. These neither moderated nor supplanted the effects of integrated counseling. CONCLUSIONS: Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment.     

Co-occurring Disorders, Emotion/Mood Literacy, and Emotion/Mood Regulation

There is a need for integrated treatment for co-occurring mental health and substance use disorders (i.e., co-occurring disorders or COD). However, evidence-based practice guidelines for COD are not yet supported by a mature body of research. Front-line programs and practitioners have no alternative but to explore ways to improve their own COD theory and practice knowledge. A rural adult outpatient addiction treatment agency in Ontario, Canada wanted to improve its ability to assist people with COD. The majority of COD involved mood and/or anxiety disorders concurrent with substance abuse or dependence. A qualitative hermeneutic phenomenology approach generated three COD practice/theory developments: adopting a functional evolutionary perspective vis-à-vis the purpose of emotion/mood experiences; focusing on enhancing COD service users’ emotion/mood literacy; and focusing on emotion/mood regulation in terms of mental health and substance use. Findings are discussed. While not generalizable, the developments may contribute to hypotheses that can be tested for generalizability.     

Comorbidity of eating disorders and bipolar affective disorders

Eating disorders--anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS) occur usually in young females. The significant pathogenic differences between patients who only restrict food, and patients with binge eating and compensatory behaviours, such as vomiting and purging were described. The prevalence of bipolar affective disorders--especially bipolar II and bipolar spectrum disorders (BS) may reach 5% in the general population. About half of the depressive episodes are associated with a "mild" bipolar disorder, and such a diagnosis is suggested by impulsivity and mood-instability. Previously, majority of research on the comorbidity between eating and affective disorders focused on depressive symptomatology, however difficulties in the reliable assessment of hypomania may obfuscate the estimation of the co-occurrence of eating disorders with BS. Epidemiological studies suggest the association between BS and eating disorders with binge episodes (bulimia nervosa, anorexia- bulimic type and EDNOS with binge episodes). Co-occurrence of such disorders with depressive symptoms probably suggests the diagnosis of BS, not recurrent depression. Bulimic behaviours, impulsivity and affective disorders might be related to the impairment of the serotonergic neurotransmission, which may result from the genetic vulnerability and early life trauma. Currently, the first-line pharmacological treatment of co-occurring eating disorders with binge episodes and BS are selective serotonin reuptake inhibitors. However in some cases, the use of mood-stabilising agents as monotherapy or in combination with serotonergic drugs may be helpful.     

Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood

BACKGROUND: A community-based longitudinal study was conducted to investigate whether personality disorders (PDs) during adolescence increase the risk for Axis I psychiatric disorders and suicidality during early adulthood. METHOD: Psychosocial and psychiatric interviews were administered to a representative community sample of 717 youths and their mothers from 2 counties in the state of New York in 1975, 1983, 1985-1986, and 1991-1993. Anxiety, disruptive, eating, mood, personality, and substance use disorders and suicidal ideation and behavior were assessed in 1983 and 1985-1986, when the participants were adolescents, and in 1991-1993, when they were young adults. RESULTS: Adolescents with PDs were more than twice as likely as those without PDs to have anxiety, disruptive, mood, and substance use disorders during early adulthood. These associations remained statistically significant after co-occurring Axis I disorders during adolescence were controlled statistically. Cluster A, B, and C PDs and DSM-IV Appendix B PDs during adolescence were all associated with elevated risk for Axis I disorders during early adulthood after co-occurring Axis I and Axis II disorders during adolescence were controlled statistically. Cluster C PDs during adolescence were associated with elevated risk for suicidal ideation or behavior during early adulthood after co-occurring psychiatric disorders and suicidality during adolescence were controlled statistically. CONCLUSIONS: Adolescents in the community with personality disorders are at elevated risk for major mental disorders and suicidal ideation or behavior during early adulthood. This increase in risk is not accounted for by co-occurring Axis I disorders or suicidality during adolescence.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.