Co-occurring Psychiatric Disorders

Abstract

This chapter discusses the importance of identification and treatment of co-occurring psychiatric disorders and substance use disorders in the effective treatment of both disorders. A review of the main epidemiological studies provides evidence of the prevalence of these comorbid disorders in community and institutional settings. A discussion of the assessment of patients includes the timing of the evaluation to ensure that psychiatric symptoms present are not the result of the substances or their withdrawal alone. Assessment also involves evaluation of the symptom severity and environmental factors that can aid/hinder recovery, and the importance of multiple longitudinal assessments using several sources of information. Given the evidence supporting the best outcomes for integrated treatment of psychiatric and substance use disorders, the chapter explores the evidence for management of specific psychiatric disorders (i.e., mood disorders, anxiety disorders, psychotic disorders, personality disorders, and eating disorders) and substance use disorders using pharmacologic and psychosocial interventions. The effectiveness of these interventions is examined in terms of reduction/abstinence of substance use, reduction of psychiatric symptoms, or both. Despite the limited high-quality evidence to evaluate treatment of individuals with co-occurring psychiatric and substance use disorders, we have cumulative evidence spanning three decades supporting integrated treatment of these disorders, when compared to parallel or sequential treatment.

Review Questions

• 1. Ms. Lopez is a 43-year-old female who has enrolled in an intensive outpatient program, and reports drinking about 1 bottle of wine per day for the past 15 years, occasionally “losing count” of how much she drinks on the weekends, having fights with her children about her alcohol use, and having multiple crying spells per week that often end in thoughts of “it would be easier if I just didn’t wake up.” Which of the following diagnoses is the most common psychiatric comorbidity among patients presenting for treatment of substance use disorders?

  • A. Bipolar disorder

  • B. Borderline personality disorder

  • C. Generalized anxiety disorder

  • D. Major depressive disorder

  • E. Schizophrenia

  Answer: D.

  Explanation: Major depressive disorder is the most common psychiatric diagnosis among patients presenting for treatment of an SUD. Bipolar disorder is less common in this group, but its presence increases the likelihood of a SUD by at least four times. Among patients in institutional settings, the highest psychiatric comorbidity was found to be in the prison population, most notably related to diagnoses of antisocial personality disorder, bipolar disorder, and schizophrenia.

  (See The ASAM principles of addiction medicine; Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study.)

• 2. Mr. Smith is a 35-year-old male recently released from jail after his second charge of driving under the influence of alcohol and cocaine. For many years he has struggled with periods of irritability and high energy, during which he doesn’t need to sleep and makes very impulsive decisions, often followed by periods of severe depression. He drinks up to 1 pint of vodka per day during most days of the week and has recently been using cocaine more frequently. Which of the following is true about epidemiological studies examining the prevalence of substance use disorders and psychiatric disorders in the United States?

  • A. The Epidemiologic Catchment Area (ECA) study examined prevalence data among adults in both community and institutionalized settings.

  • B. The National Comorbidity Survey Replication (NCS-R) was a follow-up study to collect information about changes in psychiatric and substance use disorders.

  • C. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) has been conducted in six consecutive waves to evaluate substance use across the lifetime.

  • D. The National Longitudinal Alcohol Epidemiologic Survey (NLAES) sampled the alcohol use of adults in institutionalized and household settings.

  • E. The National Longitudinal Illicit Drug Epidemiologic Survey (NLIDES) sampled household participants 16 years of age and older, to account for teenage cannabis use.

  Answer: A.

  Explanation: The ECA is the only one of these epidemiological surveys to sample adults in both community and institutional settings. The NCS-R was a study done with more than 9000 new participants rather than re-interviews. The NESARC is a third-generation epidemiologic survey, with wave 1 conducted in 2001–2002 and wave 2 conducted 2004–2005, including more than 30, 000 of the original participants. The NLAES was a household survey and did not include adults in institutionalized settings. Option e is not an actual epidemiologic study.

  (See The ASAM principles of addiction medicine; The American Psychiatric Publishing textbook of substance abuse treatment; Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study; Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication.)

• 3. Thomas is a 52-year-old male recently admitted to the psychiatric unit following a suicide attempt. He had previously required medical stabilization including admission to the intensive care unit due to delirium tremens from alcohol and for cardiac monitoring related to his intentional drug overdose. Initial evaluation reveals symptoms of depression, continuous alcohol use since age 12, and a strong family history of alcohol use disorder (AUD). Which of the following is the next best step in his treatment?

  • A. Offer no medications or treatment for depression, and refer the patient to an inpatient substance use treatment facility, as his depression is unlikely to improve if he continues to drink alcohol.

  • B. Initiate any antidepressant, as his AUD will likely subside if he has been “self-medicating” his depression.

  • C. Initiate amitriptyline, which can be helpful in treating depression and insomnia, and is inexpensive.

  • D. Initiate an antidepressant in the SSRI category, as they have been shown to improve depression and alcohol use in early-onset, severe AUD.

  • E. Initiate a mixed-mechanism antidepressant, which meta-analyses suggest are more efficacious in treating depression in this population.

  Answer: E.

  Explanation: For patients with a primary mood disorder, abstinence alone is unlikely to resolve symptoms of depression. Option b is incorrect because antidepressants appear to improve AUD outcomes only if depression also improves. Amitriptyline would not be a first-line agent in this patient, and likely should be avoided, given the potential risk for toxicity. SSRIs should be used with caution or avoided in patients with depression and early-onset alcohol use disorder, stronger family history of AUD, and more severe dependence, as drinking could worsen. Meta-analyses suggest there is more consistent efficacy in the treatment of depression with mixed-mechanism antidepressants than for SSRIs.

  (See The ASAM principles of addiction medicine; The American Psychiatric Publishing textbook of substance abuse treatment.)

• 4. Ms. Evans is a 29-year-old female who is presenting for evaluation and treatment of opioid use disorder. She was recently treated for infectious endocarditis stemming from intravenous heroin use. She describes struggling with recurrent nightmares of previous sexual trauma, flashbacks near daily of her assault, being easily startled, and avoidance of any sexual activity with her partner. Use of opioids has previously provided some respite from these symptoms, but she wishes to stop using illicit drugs. Which of the following psychotherapies was developed specifically for treatment of co-occurring posttraumatic stress disorder (PTSD) and substance use disorders?

  • A. Seeking Safety

  • B. Mindfulness-based stress reduction

  • C. Dual recovery therapy

  • D. Integrated group therapy

  • E. Acceptance and commitment therapy

  Answer: A.

  Explanation: Seeking Safety is one of the most widely known and studied type of integrated CBT, developed specifically for co-occurring PTSD and substance use disorders. Mindfulness-based stress reduction is a type of treatment focused on anxiety and stress management, but does not specifically address PTSD. Dual recovery therapy blends traditional addiction and psychiatric treatment, based on the patient’s stage of recovery, but does not specifically address symptoms of PTSD. Integrated group therapy is a type of CBT approach that has been used specifically for patients with co-occurring SUDs and bipolar disorder. Acceptance and commitment therapy involves mindfulness strategies but is also not specific for PTSD.

  (See The ASAM principles of addiction medicine; The American Psychiatric Publishing textbook of substance abuse treatment.)

• 5. Mr. Fernandez is a 60-year-old male presenting to his primary care physician for treatment of low energy and motivation, increased crying spells, decreased appetite, increased isolation, and poor self-care. He was recently fired from his job because of unexcused absences. He has struggled with similar episodes since his twenties, but never sought treatment. For the past 40 years, he has been drinking an average of 6–18 beers daily after work, and admits to drinking until he “passes out” recently, as a way to help him fall asleep. Based on available epidemiological data, which of the following psychiatric disorders is most likely to have co-occurring SUD (excluding tobacco use disorder) among patients presenting for treatment?

  • A. Mood disorders

  • B. Anxiety disorders

  • C. Trauma-related disorders (e.g., PTSD)

  • D. Personality disorders

  • E. Attention-deficit and hyperactivity disorder

  Answer: A.

  Explanation: Mood disorders (major depression, more specifically) is the most common co-occurring psychiatric disorder among patients presenting for treatment of SUDs. Although bipolar disorder is less common in this group, the presence of bipolar disorder increases the likelihood of an SUD by at least four times. In institutional settings, particularly the prison population, co-occurring severe psychiatric disorders and SUDs is most notably related to diagnoses of antisocial personality disorder, schizophrenia, and bipolar disorder.

  (See The ASAM principles of addiction medicine; Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA: the journal of the American Medical Association.)