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30.07.2014

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Substance abuse and mental disorders commonly occur together and place an incalculable burden on individuals, families, and society at large. The bidirectional, reciprocal relationship between mood and anxiety disorders and SUDs represents a challenge to the healthcare system, and one that has not been fully met.
It should be noted that patients with bipolar disorders are particularly at risk of developing SUD. All of the articles in this supplement are based on a roundtable discussion by the authors—all recognized leaders in the field of co-occurring psychiatric disorders and SUDs. Another study showed that patients with co-occurring major depressive disorder (MDD) and alcohol dependence were significantly more likely to have suicidal ideation and suicidal behavior than those with either disorder alone.5 The patients with co-occurring disorders were also found to be more impulsive. Both mood disorders and SUDs should also be viewed as multidimensional, as a host of problems frequently occur in patients with either disorder or their combination.
Accurate diagnosis and successful treatment of SUDs and co-occurring psychiatric disorders rely on a careful, comprehensive assessment (Slide 1).9 During an initial assessment, it can be difficult to distinguish between psychiatric symptoms resulting from substance use and those occurring due to an independent psychiatric disorder. In patients with co-occurring substance abuse and mood disorder, the diagnostic process does not take the traditional path of assessment, diagnosis, and treatment. Several screening instruments have been shown to be highly accurate in identifying people who have an alcohol problem and are brief and easy to use.14 These include the CAGE questionnaire and the Alcohol Use Disorders Identification Test (AUDIT) (Slide 3).
Some laboratory tests may help to provide objective evidence of problem drinking.17 Certain blood tests can detect biochemical changes associated with excessive drinking and provide biologic markers that suggest the presence of an alcohol use disorder. A careful and accurate assessment can provide the necessary information for intervention and treatment planning.
Co-occurring psychiatric and alcohol use disorders can have devastating personal and societal effects, yet little evidence exists to guide clinical treatment.
Alcohol-dependent patients commonly present with symptoms of depression or anxiety, which may be a part of acute intoxication or substance withdrawal and therefore may remit with time.
Data from controlled trials that inform pharmacologic treatment of co-occurring mood disorders and SUDs have been relatively scarce.4 A recent meta-analysis,5 however, evaluated 14 randomized, placebo-controlled, double-blind trials of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and other classes of antidepressants in the treatment of patients with a unipolar depressive disorder and concurrent alcohol or other drug dependence (N=848). Investigations of pharmacologic treatments for alcohol- or other substance-dependent individuals with bipolar affective disease have also been limited. Nearly all of the anxiety disorders co-occur more commonly with alcohol dependence than would be expected by chance alone, yet few controlled trials have investigated treatment for these indications.
Multiple agents, including SSRIs, TCAs, venlafaxine, and anticonvulsants, have demonstrated benefits in reducing the symptoms of generalized anxiety disorder (GAD) in individuals without SUDs. Posttraumatic stress disorder (PTSD) is one of the most common anxiety disorders in individuals with alcohol use problems.
Progress has been made in the recognition and treatment of co-occurring psychiatric disorders and alcohol dependence, but much work remains to be done in the area of treatment.4 Relatively few studies have evaluated the use of pharmacotherapeutic agents that specifically target alcohol use disorders concurrent with psychiatric illness.
Many SUDs are chronic,1 as is GAD,2 and depression is a recurring disorder for at least 60% of patients. The continuum of treatment begins with the acute phase (6–12 weeks), a stage marked by initiation of treatment and achievement of remission. The agent(s) that induced remission in patients with MDD or GAD should be used during the continuation and maintenance phases of treatment.
Given the high rates of co-occurrence of mood, anxiety, and alcohol use disorders, PCPs may want to identify patients likely to have comorbid mood and alcohol use disorders by screening all new patients, as well as those with associated medical conditions or other risk factors, somatic presentations, and high healthcare utilization.
A thorough evaluation can determine whether psychiatric symptoms are caused by a medical illness, medications, or SUD.3 For example, certain medical conditions, including stroke, parkinsonism, HIV infection, endocrinopathies (eg, diabetes), cardiac disease, chronic renal failure, and chronic pain syndromes, are strongly associated with major depression. Depression and anxiety are highly comorbid, and experts advise that a screening for one should always be accompanied by an assessment for the other.12 In the primary care setting, a two-step screening tool can be time-efficient and productive. As a rule, antidepressant treatment of a depressive or an anxiety disorder should not be delayed beyond a reasonable period, even if abstinence is not achieved, due to the unfavorable impact of comorbidity on prognosis.20 A history of depression or an anxiety disorder prior to the development of alcoholism is also supportive of early initiation of such treatment.
Furthermore, simultaneous treatment of co-occurring disorders may encourage adherence as patients gain relief from depressive or anxiety symptoms and alcohol cravings.
In general, pharmacotherapy alone cannot adequately address all the treatment requirements of patients with co-occurring disorders. For those individuals who desire and can afford psychotherapy, cognitive-behavioral therapy (CBT) has demonstrated effectiveness in treating depression, anxiety, and alcoholism separately and could be integrated successfully for alcohol-dependent patients with anxiety or depression.23 CBT seeks to modify negative or self-defeating thoughts or behaviors and is focused on achieving change in both. A national movement is afoot to integrate services for patients with co-occurring disorders.24 The separate mental health, substance use treatment, and primary care systems in the US have delivered fragmented and often inadequate care.
In practice, however, many patients continue to participate in treatment at different sites or require varying treatment services during different phases of treatment.
Every day we see the suffering of patients with depression, anxiety, bipolar depression, ADD, and OCD. However, a person that is consumed by intense feelings of worry or experiences fears so extreme their behavior and relationships are adversely affected might have an Anxiety Disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM), put out by the American Psychiatric Association (APA), is the standard for diagnosing mental illness in the U.S. Two of the most significant recent changes are that obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are now no longer included in the chapter on anxiety disorders. There are many signs and symptoms that provide clues a person may be experiencing anxiety disorder, such as personality changes, depression, compulsive behaviors or drug and alcohol abuse. Many of those suffering from anxiety disorders often turn to drugs, alcohol or other mood altering substances in an effort to ease their symptoms. As with any medical condition, anxiety disorder therapy can only be given after an accurate diagnosis of the illness. If you or someone you know is experiencing issues with anxiety and substance abuse, please call us toll-free at . Weiss is professor of psychiatry at Harvard Medical School in Boston, and clinical director of the Alcohol and Drug Abuse Treatment Program at McLean Hospital in Belmont, both in Massachusetts. Left untreated, co-occurring psychiatric and substance use disorders may result in troubled and unproductive lives, as this comorbidity is associated with underachievement or failure at work and school, poor health, problems fulfilling family responsibilities, abuse, violence, and legal difficulties. Conversely, among respondents with either a mood disorder or an anxiety disorder occurring during a 12-month period, at least one SUD was found among 20% and 15% of the respondents, respectively.


While it is increasingly recognized that these disorders require integrated treatment, such programs are not widespread.
The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization.
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. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. A key reason is that patients with co-occurring disorders tend to have poorer prognoses and worse overall outcomes than those with either disorder alone. One study found that 50% of alcoholics, as opposed to 20% of patients with depression, had a close personal loss within 1 year of suicide, and approximately one third had a loss within 6 weeks.4 Therefore, a high level of vigilance is warranted when individuals with co-occurring depression and substance abuse suffer a major loss. One of the most effective techniques is to develop a timeline for the co-occurring disorders, relating one to the other. It begins by identifying current problems and instituting appropriate initial treatment interventions (eg, detoxification) even when the relationship between the two disorders is not yet clear. Benzodiazepines are commonly prescribed to manage alcohol withdrawal, but their use beyond the withdrawal period should be restricted in patients with co-occurring disorders due to a high potential for abuse.1,3 The use of benzodiazepines should be limited to acute episodes targeting specific symptoms, and patients should be closely monitored while taking them. Results were variable, yet overall, the trials showed a modest beneficial effect of antidepressants on depressive symptoms. A recent double-blind, placebo-controlled trial, which examined actively drinking bipolar patients treated with valproate plus treatment as usual (lithium and psychosocial intervention) versus placebo plus treatment as usual found lower levels of alcohol consumption in the valproate-treated group.20 No differences occurred in terms of mood outcome, but those individuals receiving valproate demonstrated a trend to remit from mania earlier.
For the treatment of anxiety disorders, SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), or buspirone are recommended. Studies that have been conducted indicate that similar agents work for depressive and anxiety disorders with or without the presence of alcohol dependence. Treatment Improvement Protocols (TIP) 9: Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse.
Priority actions to improve the care of persons with co-occurring substance abuse and other mental disorders: a call to action. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. A double-blind, placebo-controlled trial of desipramine for primary alcohol dependence stratified on the presence or absence of major depression.
Imipramine treatment of alcoholics with primary depression: A placebo-controlled clinical trial. Nefazodone treatment of major depression in alcohol-dependent patients: a double-blind, placebo-controlled trial. The effect of sertraline and environmental context on treating depression and illicit substance use among methadone maintained opiate dependent patients: a controlled clinical trial. Efficacy of valproate maintenance in patients with bipolar disorder and alcoholism: a double-blind placebo-controlled study. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder.
Sertraline in the treatment of co-occurring alcohol dependence and posttraumatic stress disorder. Disulfiram treatment of patients with both alcohol dependence and other psychiatric disorders: a review. Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. Utility of combined naltrexone valproate treatment in bipolar alcoholics: a randomized, open-label, pilot study. Naltrexone and disulfiram in patients with alcohol dependence and comorbid post-traumatic stress disorder. Establishing primacy relies on determining whether the psychiatric symptoms were induced by SUD or the psychiatric disorder emerged first and substance use was a means of coping with it. Therefore, patients with these disorders may require a continuum of ongoing management, with treatment modalities, intensity of treatment, and monitoring varying by individual needs and over time. Treatment recommendations for patients with SUDs issued by the American Psychiatric Association favor a combination of psychosocial interventions (eg, cognitive-behavioral therapy, motivational enhancement therapy, interpersonal therapy, and 12-step programs) to address issues such as motivation, coping skills, dysfunctional thoughts, or social relationships, and pharmacotherapy to address the physiologic responses to substance use. Long-term treatment is associated with better outcomes, but the type of treatments used, their intensity, and the frequency of patient monitoring must be tailored to the individual patient’s needs. Association between concurrent depression and anxiety and six-month outcome of addiction treatment. Safety and efficacy of escitalopram in the long-term treatment of generalized anxiety disorder. Efficacy and tolerability of paroxetine for the long-term treatment of generalized anxiety disorder. A double-blind comparison of escitalopram and paroxetine in the long-term treatment of generalized anxiety disorder. Follow-up of 180 alcoholic patients for up to 7 years after outpatient treatment: impact of alcohol deterrents on outcome. Acamprosate and relapse prevention in the treatment of alcohol dependence: a placebo-controlled study.
Combined efficacy of acamprosate and disulfiram in the treatment of alcoholism: a controlled study. However, because PCPs are often not aware of or alerted to these problems, it would seem advisable that patients presenting with either a psychiatric or an alcohol use disorder should be evaluated for both conditions.3 Establishing the presence of co-occurring disorders may be difficult, but it is necessary for appropriate and realistic treatment planning.


Indeed, MI may improve adherence with treatment recommendations not only for alcoholism but also for depression and anxiety disorders. Six-month outcomes associated with a brief alcohol intervention for adult in-patients with psychiatric disorders. Treating Co-Occurring Disorders: A Handbook for Mental Health and Substance Abuse Professionals.
Treatment Improvement Protocols (TIP) 9: Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. This can, however, alter the brain’s chemistry and make anxiety issues even more intense and complicated.
Having both an anxiety disorder and substance addiction is called a co-occurring disorder, and our dual-diagnosis specialists will prescribe the appropriate medication if needed to reduce anxiety, helping to ease the mind and calm the nerves. Each patient at Inspire Malibu’s Anxiety Disorder Treatment Centers receives a thorough diagnostic evaluation.
These disorders can be controlled with the proper medication, as well as learning methods to successfully cope with anxiety or panic attacks.
Co-occurring disorders frequently have a complex and bidirectional relationship and may require longitudinal, repeated assessments to establish correct diagnosis. Thus, the onus to provide comprehensive management for patients with dual disorders falls to individual practitioners. Weiss, MD, on the importance of early diagnosis, as well as his pragmatic approach to the screening and diagnosis of these disorders. This approach can help determine the chronology of symptom development, the presence or absence of symptoms during extended substance-free periods, and the impact of each disorder on the presentation, clinical course, and outcome of the other. This helps to accurately reconstruct the chronology of the patient’s disorders and also helps the patient to recognize any relationships between substance use and mood disorders. Whether psychiatric symptoms are the result of a mood disorder or substance abuse might not be determined until stable abstinence is achieved, unless the symptoms are of sufficient intensity or duration that they are unlikely to have been caused by the specific substances used by the patient. The Alcohol Disorders Identification Test: Guidelines for Use in Primary Care, 2nd Edition. The American Psychiatric Association (APA) advises that failure to treat a concurrent psychiatric disorder reduces the likelihood that the treatment for a substance use disorder (SUD) will be effective.1 Indeed, the effects of nontreatment were demonstrated in a prospective study assessing alcohol-dependent patients for 1 year following hospitalization for alcohol dependence,2 in which untreated depression was directly associated with a shorter time to first drink. In the face of limited data, the best course may be to treat with agents known to be effective for the specific anxiety disorder while being mindful of contraindications to the use of these agents in individuals with alcohol dependence.
Groups receiving either active medication had longer periods of abstinence and less craving; however, combined treatment showed no advantage. The SSRIs escitalopram, fluoxetine, paroxetine, and sertraline, as well as the SNRIs duloxetine and venlafaxine, are indicated for both major depression and specific anxiety disorders, such as GAD, panic disorder, PTSD, social phobia, and obsessive-compulsive disorder.29 Each of these agents, however, is indicated for one or more particular anxiety disorder(s), and clinicians are advised to consult relevant prescribing information when selecting treatment. A third possibility exists—that the two disorders developed independently of each other, albeit becoming intermingled over time and serving to exacerbate each other. The decision to continue with maintenance treatment in depression is based on factors that include the likelihood of recurrence (Slide 2),8,9 the severity of depressive episodes, any treatment side effects experienced by the patient, and patient preference.
The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Characterization of the longitudinal course of improvement in generalized anxiety disorder during long-term treatment with venlafaxine XR.
A clinical interview of patients with a positive screen (score ≥8) can subsequently verify the diagnosis of an anxiety disorder as well as other psychiatric comorbidities.
With the fifth edition (DSM-5), released in May 2013, the APA has altered and updated the criteria and categories of anxiety disorder. Furthermore, the requirement in some anxiety disorders that a person must recognize that their anxiety is unreasonable or excessive has been removed entirely. Patients can then begin to explore the underlying issues surrounding their anxiety in a safe and caring environment using proven cognitive therapy techniques.
A number of reliable instruments have been developed to improve screening and assessment in both primary care and mental health settings, but controversy persists regarding the best approach to treatment. Severity ratings are based on the patient’s history of problems, present condition, and subjective assessment of treatment needs in one or more areas.
The results also showed that among those patients with depression (Slide 1),2 taking antidepressants at the time of discharge increased the likelihood of an individual remaining abstinent during the follow-up period. Considering the insufficiency of existing evidence, additional controlled trials are clearly needed to help clinicians guide their patients with co-occurring disorders toward sustained remission and recovery. A fundamental issue, for example, is whether to treat a mood or an anxiety disorder in the presence of ongoing alcohol or drug abuse. Brady, MD, PhD, focuses on general treatment considerations that guide the management of these patients and also provides practical guidelines in the selection of the most appropriate pharmacotherapy.
The ASI can be helpful in conducting a comprehensive interview, treatment planning, and follow-up. Importantly, there was no direct impact of antidepressant treatment on alcohol consumption, but in those studies in which the medication had a positive effect on the treatment of depression, a significant reduction in alcohol use also occurred.
Although recent recommendations suggest that concurrent substance abuse should not impede treatment of psychiatric symptoms, more evidence is required to facilitate decision making during acute treatment. Further, relapse and recurrence are common among individuals with co-occurring disorders, and the issue of long-term treatment typically needs to be addressed. Therefore, it is important that physicians who care for this patient population weigh the most recent evidence on effective and integrated treatment of individuals with co-occurring mood, anxiety, and alcohol use disorders.



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