Comorbidity: Substance Use Disorders and Mental Illness - Research Paper Example

?Comorbidity: Substance Use Disorders and Mental Illness This is a research paper discussing the comorbidity aspects of substance abuse and accompanying mental illness. Reverse case also is true. The paper has discussed the various obstacles in isolating mental illness from drug abuse and vice versa and the problems concerned with dual diagnosis. However, the National Institute of Drug Abuse (NIDA) suggests that the both the conditions should be ideally treated concurrently in spite of practical difficulties in the comprehensive treatment of Comorbidity. Various studies also indicate concurrent treatment of both the disorders. Introduction Comorbidity is characterized by the presence of concurrent illnesses in the same person. Drug abuse disorders often coexist with mental disorders. As such, drug abuse can lead to mental disorders and vice versa. This suggests that both the illnesses have some common risk factors. It has been found that at least 60 % of the people with drug abuse disorder acquire another form of mental disorder. This phenomenon is known as comorbidity. But it does not mean, one disorder caused the other although one might have surfaced first (NIDA, 2007). People with substance abuse and psychiatric comorbidities also have attendant issues such as “relationship problems, problems with support, housing and employment” (Hesse, 2009, p 328). Poor prognosis People with alcohol addiction and drug addiction are found to have comorbid depression though not all of them. Depression forces a person with drug abuse disorder to seek treatment for addiction. They tend to stop using the drugs and seek treatment for de-addiction so that their depression could be overcome. It can be suggested therefore that depression can mitigate the possibilities of continued drug use whilst on treatment or afterwards. When comorbid symptoms become chronic, quality of life suffers. As such the clinician should therefore bestow greater attention even though the symptoms are due to drug abuse or not. Depression has also been found to be remitting in drug users whether on treatment or on abstinence. It is because patients present for treatment when their problems become acute. However, the patients continue to experience comorbid symptoms during and after treatment in spite of treatment for drug abuse. Clinicians have to prioritize various concerns of the patient and draw a pragmatic treatment plan. (Hesse, 2009). It has been already demonstrated that patients with substance abuse present with psychiatric disorders (Grant et al, 2005) Question arises whether comorbid mental illness can be treated whilst on substance abuse treatment. That is, whether there are indirect benefits of treating comorbid conditions on the outcomes of substance use treatment. It is suggested that it is quite possible if the mental illness comorbidity is a direct result of drug abuse or an important obstacle for recovery from substance abuse disorders (Hesse, 2009) Some of the causes for the common co-occurrence of drug abuse and mental disorders are. overlapping genetic vulnerabilities, overlapping environmental triggers, involvement of similar brain regions, developmental nature of drug abuse and mental illness ( (Brady & Sinha, 2007). Research has shown that the gene catechol-O-methyltransferase (COMT) is of two types: “Met” and “Val”. One of them is known to cause schizophrenia. The variant Val found in the individuals is responsible for causing symptoms of psychosis and schizophrenia when they start using cannabis in their adolescence. As such there are complex interactions between genetic disposition, drug abuse and age towards risk for development of mental disorder (Caspi, et al., 2005). There may be a genetic pre-disposition in individuals towards mental illness and addiction or towards a tendency to have the second disorder as soon as the first one appears. Overlapping of environmental triggers such as stress, trauma due to sexual abuse for instance, and early exposure to drugs can result in addiction to drugs and acquisition of mental illness especially in people having genetic pre-dispositions. There are similar regions in the brain vulnerable to drug abuse as well as mental illness. For example, brain circuits connected to reward processing and stress response are vulnerable to abused substances. They also show abnormalities in some mental illnesses. Further, both the disorders are developmental in that they occur when brain undergoes developmental changes that are dramatic during the periods of adolescence or childhood. As such any exposure to drug abuse at these stages can alter the ways of brain development vulnerable to mental illness. This is just as early onset of mental illness increasing the pre-disposition to drug abuse. NIDA reports that people with mental illness are twice likely to be affected with a substance abuse disorder. Similarly, patients with drug abuse disorders are also twice likely to acquire mental illness. (NIDA, 2007). Mental illness among adults Serious mental illness (SMI) among adults was studied in a survey by a National Household Survey on Drug Abuse (NHSDA) in 2001 among people of age 18 and above. Serious mental illness is defined as a diagnosable, behavioral or emotional disorder meeting the criteria of the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM IV) which should have resulted in impairment of one or more daily life functions. SMI was found to be prevalent in 9.2 % of people aged 18 and above in the year 2003. The percentage differed from state to state. The SMI is associated with the consumption of illicit drugs and cigarette smoking as also educational status, joblessness and urbanicity (OfficeOfAppliedStudies, 2008 updated). Depression and substance use disorders Major depression occurs with the use of nicotine, alcohol and illicit drug abuse in the range of 32% to 54 %. As already mentioned, individuals with major depression are more likely to acquire substance abuse disorders and those with substance use disorders are at a greater risk for development of mental depression than general population. The problem is the clinical similarities between both the disorders. Irritability, sleep disturbances, anxiety, attention deficit often are the symptoms of major depression associated with substance abuse. Depressive symptoms also occur at the time of acute and chronic withdrawal of drugs. The neurobiological similarities between both the disorders cause overlapping of symptoms and high incidence of comorbidity (Brady & Sinha, 2007). In particular, “extrahypothalmic CRF and HPA axis abnormalities and alterations in catecholamine, serotonin, GABA, and glutamate systems are associated with major symptoms” (Brady & Sinha, 2007). Diagnosis of comorbidity There should be a comprehensive approach for treatment of both the disorders simultaneously. Such people with comorbidity can be identified showing more symptoms than those suffering by one of the disorder. Even those who have no comorbidity but with mental disorder alone can eventually develop tendency to substance abuse which will cause subsequent mental disorders. Therefore diagnosis and treatment at the early stages of one disorder will reduce the risk for development of the other co-occurring disorder (NIDA, 2007). Treatment For comorbid depression, antidepressant medications are an important option. The medications include serotonin-specific reuptake inhibitors (SSRI) like fluoxetine or sertaline, or tricyclic antidepressants such as desipramine or imipramine (Hesse, 2009). A meta-analysis of antidepressants for comorbid depression in the patients with substance abuse history showed clear effects on depressive symptoms. This involved 14 studies involving 848 patients randomly assigned with either medicine or placebo. Effects were greater in patients who had been abstinent from alcohol and substances for minimum one week before starting of medication. Further, it has also been confirmed that there is an indirect effect of treating depression on substance abuse (Hesse M. , 2004) and (Nunes & Levin, 2004). Summary of various studies does indicate that antidepressants administered in the treatment of comorbid depression can impact on both depressive symptoms as well as substance use. (Hesse, 2009). Depressive and anxiety disorders are extremely common comorbid psychiatric disorders associated with substance abuse and dependence throughout life time in as many as 50 % of individuals addicted to opioids. Percentage of those with Schizophrenia or Bipolar 1 disorder is even more. Integrated treatment through psychiatric and medicare for agonist and substance abuse under programs called one-stop shopping has had positive effects. National Institute on Drug Abuse‘s projects have demonstrated that integrated services have yielded positive result on compliance by patients (First & Tasman, 2009). Alcohol and other drug abusers present symptoms for treatment with benzodiazepines or other sedatives if they are not chronic abusers. Benzodiazepines or other sedatives have no effect on those still on drug abuse. They tend to misuse even medications as they encourage them to continue with the primary drug of abuse. The patients must to be hospitalized and treated for detoxification if drug abusers become symptomatic of drug toxicity. Those with dependence disorders should be asked to abstain from abusable medications. This should be the goal of treatment especially during the first six months of abstinence. Those not having drug dependence disorders can be given benzodiazepine after detoxification and the implications can be different from those o dependence disorders. Relapse will occur in patients who self-administer benzodiazepine when they are on benzodiazepine abstinence. However, it cannot be called a relapse in those with substance abuse disorder returning to the use of benzodiazepine since after- effects could be manageable. Those who are on long-term benzodiazepine therapy have the tendency to develop Major Depressive Disorder, Panic Disorder, or Generalized Anxiety Disorder (First & Tasman, 2009). Comorbidity induces treatment-seeking behavior. Though alcohol abusers do not seek treatment, substance abusers do develop treatment seeking tendencies. Alcohol dependence generally develops in the pattern of first starting with heavy drinking during the late twenties of the individuals, interfering with functioning in multiple life areas during their early thirties, loss of control followed by social and work related problems and severe long term consequences during the late thirties and early forties. This pattern is the same for men and women but the age periods for women are later than men Comorbidity depressive disorders along with other mental disorders are also quite common and treatment outcomes significantly differ (First & Tasman, 2009). Life time comorbidity of depression is often found in abusers of alcohol, nicotine and other substances at 40 %, 30 % and 17 % respectively. Depressed patients with comorbid substance dependence or abuse experience in early ages are likely have, “more depressive symptoms, grater functional impairment, and a history of more previous suicide attempts than patients with depression alone. Because pharmacokinetic and pharmacodynamic drug interactions (e.g. between phenylpiperidine opioids and SSRIs and psychosocial consequences of Substance Dependence or Abuse, have a significant impact on response and recovery rates from depressive disorders, a combined therapeutic approach addressing the depression and any comorbid use disorder is mandatory.” (First & Tasman, 2009, p. 281). Dual diagnosis Both substance abuse and withdrawal symptoms resemble mental illness. This creates a problem in determining whether the problems are due to psychopathological process or substance-induced process (Schuckit, 1983). Some mental disorders occur on their own but are masked by substance abuse (Brady, Killeen, Brewerton, & Lucerini, 2000). Besides, it has been difficult to pinpoint a particular problem with a particular disorder when patients present with multiple impairments. The overlapping diagnostic criteria “between some mental and substance use disorders that co-occur with great frequency truly represent two nosologically separate entities or are better conceptualized as one disorder” (Widiger & Shea, 1991, p. 122). Dual diagnosis affects treatment significantly in that such individuals with dual disorders utilize services more frequently and incur higher health care costs. It also results in poorer retention in treatment, compromised treatment compliance and treatment outcome. Longitudinal studies show relapse to substance use following substance abuse treatment. The dual disorder patients experience worse outcomes in spite of spending more for their treatment. They have to resort to more expensive treatments such as inpatient hospitalization and emergency room visits for short periods to address their acute symptoms but at the same do not get an ongoing care (Miller & Weisner, 2002). Methodological issues Dual diagnosis or comorbidity conditions have not been uniformly defined. Because of this, prevalence rates are diverse and difficult to compare. Substance abuse is defined in varying degrees within the perspectives ranging from problem use of a substance to abuse or dependence based on DSM criteria For instance, nicotine does not come under substance abuse in dual diagnosis studies although there are individuals in large numbers using nicotine with mental illness and substance abuse. This is despite the fact that nicotine causes depression and schizophrenia. Further, there is no integration between mental health treatment system and substance abuse treatment system which impacts on the dual diagnosis research. Dual diagnosis research has two distinct areas of investigation i.e research on substance abuse in individuals with mental illness and mental illness among the primary substance abusers. Hence both aspects are to be studied for meaningful outcomes (Herson, Turner, & Beidel, 2007) Symptoms overlap Symptoms of mental disorders overlap with the symptoms of substance abuse disorders which renders diagnosis of either category difficult. For instance, DSM has listed the problems related to social functioning as symptoms of schizophrenia as well as substance use disorders (Herson, Turner, & Beidel, 2007) “This overlap can work against identification of the psychiatric disorder in some cases. For example, high rates of dual substance use and bipolar disorders leads to an under-diagnosis of bipolar disorder, because of the often incorrect assumption that the behavioral manifestations of bipolar disorders are secondary to substance use” (Herson, Turner, & Beidel, 2007, p. 52). In mental health care, substance use disorders are not given attention which results in adverse impact on overall functioning of the individuals with multiple impairments. Confusion prevails as to whether a given impairment is due to substance abuse disorder, psychiatric disorder, both together or none of these. For example, impact of substance abuse cannot be determined when the mental illness has seriously affected the whole body functioning. As already mentioned, substance induced disorders often mimic psychiatric disorders. For instance, long-term alcohol consumption and withdrawal result in symptoms of psychotic nature. Abuse of amphetamines would result in symptoms that are similar to that of schizophrenia. Alcohol consumption and withdrawal related symptoms are similar to that of anxiety disorders. Stimulant use and withdrawal from depressant drugs produce symptoms that are akin to panic and obsessive behavior. Differential diagnosis necessary for these types of situations has no clear-cut rules. (Herson, Turner, & Beidel, 2007). “ For example, Rosenthal and Miner (1997) review the issue of differential diagnosis of substance-induced psychosis due to schizophrenia and stress that medicating what appears to be acute psychosis due to schizophrenia but is actually substance-induced psychosis is not only incorrect but also ineffective treatment” (Herson, Turner, & Beidel, 2007, p. 53) Alcohol Acute effects of alcoholism are dependent upon the time course of alcohol consumption during the first 30 minutes of consuming even a small quantity (ascending curve) which is associated with mood elevation, followed by sedative and anxiolytic effects. Blood alcohol concentration (BAC) depends upon the amount consumed. Based on the BAC, consequences of intoxication differ. Acute consumption results respiratory depression especially combined with tranquilizers followed by coma and death. Acute complications of dependence on alcohol are alcohol-induced psychotic disorder and Wernicke enceleopathy. The former occurs both during the periods of active drinking as well as during withdrawal. People experience visual and auditory hallucinations and schizopherniform like delusions. The alcoholic hallucinosis occurs in clear consciousness as opposed to derilium tremens. The alcohol induced psychotic disorder lasts for 10 to 15 days. For the second type, Wernicke enceleopathy being a life threatening conditions, the patients need to be treated under intensive care unit with large amounts fluid and electrolyte support and ventilator that is mechanically assisted (Ruiz, Strain, & Langrod, 2007). Stoppage of chronic alcohol consumption in people for a few hours can result in withdrawal symptoms in them. While they vary in intensity, generally start with tremulousness and signs of sympathetic overactivity like palpitations and sweating. It can result in delirium tremens in the extreme cases within 24 to 48 hours of alcohol withdrawal. The condition is characterized by clouding of consciousness, phonemes such as auditory and vivid visual hallucinations of persecutory type and seizures. People will also see animals or dwarfed people in their vision termed as Lilliputian hallucinations. These are but rare. A more common type is tactile hallucinations characterized by feeling of insects crawling over the skin. Mortality rates in respect of derilium tremens is between 5 % to 15 %. The withdrawal experience is mild to severe from the start to finish. A chronic alcoholic abstinent for more than 72 hours is not likely to have severe withdrawal symptoms if he has no progressive symptoms after withdrawal (Ruiz, Strain, & Langrod, 2007). Comorbidity Alcoholism occurs along with nicotine dependence and narcotics dependence. 89 % of people addicted to cocaine also happen to be chronic alcoholics. Comorbidity of alcoholism along with other addictive disorders starts in the early age of onset of problem drinking. These people are prone to acquire several addictive or impulse dyscontrol disorders or it may be due to familial or psychological backgrounds that do not curb substance use. They are also susceptible to high rates of comorbidity with other psychiatric disorders. Alcoholism is associated with affective and anxiety related disorders. About 33 to 67 % of people with alcoholism also have depression of severe kind. 60 % of people with bipolar disorder either indulge in substance abuse or indulge in heavy dosage of alcoholism. Those with anxiety and post-traumatic disorder are susceptible to alcohol abuse and dependence. Antisocial personality disorder is also associated with chronic alcoholism. Though it is too early to say co-occurrence of other psychiatric disorders and alcoholic consumption, it may be related to impulse dyscontrol (Ruiz, Strain, & Langrod, 2007). Treatment Although acute effects of alcohol are not treated for the symptoms since they would subside overtime, medical intervention will be necessary to prevent profound respiratory depression. Flumazenil which is benzodiazepine antagonist will reverse the alcohol related respiratory depression and coma. This should be under expert medical supervision along with a ventilator therapy if necessary. The other condition Wernicke syndrome requires intravenous hydration and thiamin. Magnesium sulphate is used to prevent seizures. Mortality rates for Wernicke encephalopathy are stated to exceed 50 %. (Ruiz, Strain, & Langrod, 2007). Treatment of depression in drug-dependent patients It has been already discussed that people with substance use disorders are often associated the symptoms of depression and anxiety. It is also the case that people with mood and anxiety disorders are susceptible to the risk for substance use disorders. Moreover mood-disordered substance abusers have poor prognoses. In general population substance abuse and mood disorders being common, some individuals are likely to have both the disorders. A subgroup having mood disorders contribute to the etiology of substance abuse. This can happen through self-medication. This is because they believe that it gives them temporary relief from the symptoms of depression or anxiety (Nunes & Quitkin, 1998). Treatment in cocaine abuse Desipramine was tested to know whether it could control directly the cocaine abuse behavior independent of its anti-depressant effects. Depression was not an inclusion criterion in the said study. In the large trial, it was found that desipramine had the favorable effect on cocaine use and craving. There was no change in the effect when a small subgroup with major depression was removed from the study. This confirmed that desipramine effect was independent of antidepressant effects. Subsequent placebo controlled trials failed to replicate these results. Fluoxetine also demonstrated its use in the treatment of cocaine abuse (Nunes & Quitkin, 1998). Antidepressant treatment in opiate addiction Several studies have demonstrated that TCAs had a positive anti-depressant effect in opiate addicts but there was no effect on drug abuse outcome. These findings show that depression can be isolated and treated from among methadone maintained opiate addicts. This is possible in cases of depression which is an independent disorder with no contribution to the etiology of addiction. Imipramine which is standard anti-depressant was tried for treatment of depression and drug abuse in methadone patients. The study concluded that imipramine exerted a strong antidepressant effect in methadone patients who were specifically recruited. The effect was not the same in patients with illicit drug abuse. The authors inform that these studies were inconclusive at the time their book was written. However, they have suggested newer antidepressant drugs like tricyclic antidepressants may be of value because of their lesser side effects and greater margin for safety. (Nunes & Quitkin, 1998) They also “exert a stronger effect on depression or substance abuse or both “. (Nunes & Quitkin, 1998, p. 73). Treatment modalities as suggested by NIDA The National Institute of Drug Abuse (NIDA) states that scientific evidence suggest that comorbid conditions must be treated concurrently though it is a difficult proposition in view of barriers to comprehensive treatment of comorbidity. A medication that is effective for treatment of opioids, alcohol and nicotine abuse which should also take care of mental health disorders is Bupropion (trade name Wellbutrin, Zyban). It has been recommended for treatment of depression and nicotine dependence. It can also help in reducing the craving for the abuse of the drug methamphetamine (NIDA, Comorbidity: Addiction and other mental illnesses, n.d) Apart from medications, behavioral therapies are also suggested for successful outcomes. For adolescents Multisystemic therapy (MST) that targets attitudes, family, peer pressure, school and neighborhood culture is recommended. These are associated with antisocial behavior in children and adolescents who indulge in abuse of drugs (NIDA, n.d) Other therapies found on the NIDA‘s website are reproduced below “BSFT targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co-occurring problem behaviors. These problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behaviors. Cognitive-Behavioral Therapy (CBT) CBT is designed to modify harmful beliefs and maladaptive behaviors. CBT is the most effective psychotherapy for children and adolescents with anxiety and mood disorders, and also shows strong efficacy for substance abusers. (CBT is also effective for adult populations suffering from drug use disorders and a range of other psychiatric problems.)” (NIDA, n.d). Conclusion The brief research on the literature above shows that comorbidity in substance abuse and mental illness is still a vexed problem offering no short term or short-cut methods of treatment. As suggested by the NIDA, concurrent treatment may be ideal. It is only with elimination methods that the problems of comorbidity could be treated. It may be recalled that First and Tassman referred to above in page 5 have recommended a combined therapeutic approach as a mandatory measure in such conditions. Bibliography Brady, K. T., & Sinha, R. (2007). Co-Occurring Mental and Substance Use Disorders: The Neurobiological Effects of Chronic Stress. Focus (American Psychiatric Association) , 5, 229-239 Available at < > accessed on 5 May 2011. Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S. (2000). Comorbidity of pyschiatric disorders and postraumatic stress disorder. Journal of Clinical Psychiatry , 61 (Suppl 7), 22-32. Caspi, A., Moffitt, T. E., Cannon, M., McClay, J., Murray, R., Harrington, H., et al. (2005). Moderation of the Effect of Adolescent-Onset Cannabis Use on Adult Psychosis by a Functional Polymorphism in the Catechol-O-Methyltransferase Gene:Longitudinal Evidence of a Gene X Environment Interaction. Biol Psychiatry , 57, 1117-1127 in NIDA. (n.d). Comorbidity: Addiction and other mental illnesses. Retrieved May 4, 2011, from National Institute of Drug Abuse: http://www.nida.nih.gov/researchreports/comorbidity/treatment.html. First, M. B., & Tasman, A. (2009). Clinical Guide to the Diagnosis and Treatment of Mental Disorders . Oxford, U.K.: John Wiley and Sons . Herson, M., Turner, M. S., & Beidel, C. D. (2007). Adult psychopathology and diagnosis (5 ed.). New Jersey: John Wiley and Sons. Hesse, M. (2004). Achieving abstinence by treating depression in the presence of substance-use disorders. Addictive Behaviours , 29, 1137-1141 in Miller M Peter and Miller Micahel Peter (2009) Evidence-Based Addiction Treatment , Academic Press . Hesse, M. (2009). Treating the Patient with Comorbidity. In P. M. Miller, & P. M. Miller, Evidence-Based Addiction Treatment (pp. 327-344). London: Academic Press. Miller, W. R., & Weisner, C. M. (2002). Changing susbstance abuse through health and social systems . New York: Springer. NIDA. (n.d). Comorbidity: Addiction and other mental illnesses. Retrieved May 4, 2011, from National Institute of Drug Abuse: http://www.nida.nih.gov/researchreports/comorbidity/treatment.html NIDA. (2007). National Institute on Drug Abuse; Comorbid Drug Abuse and Mental Illness- A Research Update from the National Institute on Drug Abuse-2007. Retrieved May 3, 2011, from Nunes, E. V., & Levin, F. R. (2004). Treatment of Depression in patients with alcohol or drug dependance: A meta-analysis. Journal of American Medical Association , 291 , 1887-1896 in Miller M Peter and Miller Michael Peter (2009) Evidence-Based Addiction Treatment. Academic Press . Nunes, V. E., & Quitkin, M. F. (1998). Treatment of Depression in Drug-Dependent Patients: Effects on Modd and Drug Use. In S. L. Onken, Treatment of drug-dependant individuals with comorbid mental disorders. Rockville, MD: Diane Publishing. OfficeOfAppliedStudies. (2008 updated). 2003 State Estimates of Substance Use : Serious Mental Illness among Adults. Retrieved May 3, 2011, from Office of Applied Studies : http://www.oas.samhsa.gov/2k3State/ch6.htm Ruiz, P., Strain, C. E., & Langrod, J. (2007). The Substance Abuse Handbook. (revised, Ed.) PA: Lippincott Williams and Wilikins. Schuckit, M. A. (1983). Alcoholism and other psychiatric disorders. Hospital and Community Psychiatry , 34 (11), 1022-1027 in Miller R William and Weisner (2002 ) Changing Substance Abuse through health and social systems, New York Springer. Widiger, T. A., & Shea, T. (1991). Differentiation of Axis 1 and Axis II disorders. Journal of Abnormal Psychology , 100 (3), 399-406 in Miller R William and Wesiner Meyer Constance (2002) Changing Substance absue through health and social systems , New York, Springer page 122. Read More