Despite a growing body of evidence that integrated care is important in treating individuals with addiction and comorbid psychiatric disorders, such care remains in short supply. But efforts by scientists and policy makers aim to improve access to such treatment. Substance abuse disorders often occur in patients with other psychiatric illnesses, yet few such individuals receive treatment for their conditions despite the serious health and other consequences that often result. An estimated 17.5 million adults had a serious mental illness in 2002 based on the National Survey on Drug Use and Health (previously called the National Household Survey on Drug Abuse), a nationally representative survey of more than 68 000 US individuals. About 4 million (23%) were also dependent on or abusing alcohol or illicit drugs (http://www.oas.samhsa.gov/2k4/coOccurring/coOccurring.htm). But more than half of these individuals received no treatment for either condition, about one-third received treatment only for their mental illness, 2% received only specialty substance abuse treatment, and just 12% received care for both conditions. Common vulnerabilities There are a number of potential explanations why substance abuse and other types of psychiatric illness frequently occur together, explained Nora D. Volkow, MD, director of the National Institute on Drug Abuse (NIDA) in an interview. She explained that there may be common genetic or environmental factors that lead to both conditions. Additionally, because substance abuse and other mental illnesses affect overlapping brain circuits, brain changes related to one disorder may lead to another. There may also be complex interactions between such factors. One environmental factor that has been strongly associated with the development of both addiction and other mental illnesses is exposure to stress during childhood or adolescence. For example, a child raised in a household in which there is parental neglect, physical abuse, or sexual abuse has an elevated risk of developing a substance use disorder, depression, or an anxiety disorder. “Which of these trajectories you take when you get exposed to these environmental stimuli is a function of genetic vulnerability factors and also modes of coping that occur in the household where your brain grew up,” Volkow said. Common brain circuitry is involved in the development of both addiction and other mental illnesses. The amygdala, for example, plays an important role in regulating emotional reactions and is thought to be involved in depression. Chronic use of illicit drugs results in changes in the amygdala and other regions associated with emotional regulation, which in turn may cause chronic drug users to become more vulnerable to depression. Comorbid addiction and mental illness may be the result of overlapping brain circuits or common genetic and environmental factors. “The drugs are impairing the resilience of the brain areas that are responsible for regulating emotions when something adverse happens to you,” Volkow said. Some research findings support the idea that certain types of substance use may lead to or exacerbate mental illness. For example, there is epidemiological evidence linking early cigarette smoking to the development of anxiety disorders later in life, Volkow said. Additionally, having a psychiatric condition such as schizophrenia, attention-deficit/hyperactivity disorder, depression, or an anxiety disorder increases an individual's likelihood of experimenting with or taking drugs, perhaps to mitigate some of the psychiatric symptoms they are experiencing, Volkow said. For example, as many as 90% of individuals with schizophrenia smoke, according to a 2009 NIDA report (http://www.drugabuse.gov/PDF/RRComorbidity.pdf), and there is some evidence that doing so may help patients manage their symptoms, although it exposes them to other risks. Results of a recent prospective epidemiological study reinforce the idea that mental illness may be a risk factor for developing a substance abuse disorder (Swendsen J et al. Addiction. doi:10.1111/j.1360-0443.2010.02902.x [published online ahead of print March 10, 2010]). The study involved 10-year follow-up interviews with 5001 individuals surveyed initially between 1990 and 1992 for the National Comorbidity Survey. The researchers found that having a mental disorder at the time of the initial survey was significantly associated with the onset of a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of dependence on nicotine, alcohol, or drugs. Mood disorders, in particular bipolar disorder, were most strongly associated with the onset of a substance use disorder. The authors note that such findings may have important implications for prevention efforts because early treatment or prevention of mental illness might prevent an estimated 15% to 40% of cases of secondary substance abuse. “This should reinforce the early screening for both conditions,” Volkow said. “If you do have a kid who is using high quantities of drugs to try to overcome something that is not yet clinically relevant, you could intervene very early on and perhaps even prevent the full manifestation of the mental illness.” Integrated treatments Patients with comorbid addiction and another mental illness tend to have poorer outcomes than other patients, and can be difficult to manage, said Volkow. “Concurrent treatment of both conditions is crucial to be able to address one or the other,” she said. “Without it, we are very unlikely to be successful.” Patients who are admitted for psychiatric treatment but who do not receive substance abuse treatment are likely to relapse to drug use after they are discharged, Volkow noted. “The moment that they relapse into drug taking, their ability to become compliant with medications or psychotherapeutic intervention is basically lost,” she said. Results from a recent placebo-controlled trial suggest how important dual treatment is. Helen M. Pettinati, PhD, of the Center for Studies of Addictions at the University of Pennsylvania in Philadelphia, and colleagues randomly assigned 170 individuals with depression and alcohol dependence to receive 14 weeks of treatment with the antidepressant sertraline, the addiction treatment naltrexone, the combination of the 2 drugs, or a double placebo (Pettinati HM et al. Am J Psychiatry. 10.1176/appi.ajp.2009.08060852 [published online ahead of print March 15, 2010]). All patients also received weekly cognitive behavioral therapy. Patients in the naltrexone with sertraline group had the highest rate of abstinence from alcohol use, 53.7%, compared with 21.3% in the naltrexone group, 27.5% in the sertraline group, and 23.1% in the control group. Patients in the combination treatment group were also more likely to report not being depressed at the end of treatment (83.3%), compared with the naltrexone group (68.8%), the sertraline group (48.1%), and the control group (56%). However, the differences in depression outcomes between groups did not reach statistical significance, although there was a trend in that direction, according to the authors. Charles P. O’Brien, MD, PhD, one of the study's authors and director of the Center for Studies of Addictions, said that he and his colleagues have been recommending such comprehensive therapy, but until now no one had performed a trial comparing this combination of drugs with either drug alone. He said the results are even stronger than the researchers expected, but will need to be replicated. O’Brien, who emphasized the importance of using both behavioral and pharmacotherapies to treat such dually diagnosed patients, said more and better education is needed for all clinicians and other professionals who provide care to patients with these comorbidities. He explained that some therapists are biased against the use of medications to treat patients with substance abuse problems, despite evidence that medications improve outcomes. “We believe that it is wrong to deny your patient medications that work, but it would be equally wrong to deprive them of talk therapy,” he said. He also emphasized the critical importance of truly comprehensive treatment that involves a full evaluation of each patient for mental illness, substance abuse, and related psychosocial problems, such as the need for marital counseling, employment counseling, or referral for legal assistance. “I can't stress enough how important it is to give the patient a full evaluation and address each of their individual problems,” O’Brien said. In fact, O’Brien, who is also chair of the Substance-Related Disorders Work Group of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) task force, noted that the DSM-5 will include cross-cutting measures for evaluating addiction and mental illness so that all patients will be evaluated for both. Fragmented care Despite the compelling evidence base supporting integrated treatment for patients with comorbid addiction and other mental illnesses, such care is fragmented. In the United States, care for most mental illnesses is provided by primary care physicians or psychiatrists. In contrast, care for addiction is provided almost exclusively at specialty treatment centers by individuals of various disciplines, often with little input from physicians. A. Thomas McLellan, PhD, a cofounder of the Treatment Research Institute in Philadelphia, which works to boost evidence-based care for substance abuse, explained that the separate payment systems in substance abuse and mainstream medical care have been a key barrier. As a result of this segregation, a patient may be getting care in 3 different settings with no effective communication between the clinicians providing their mental health, substance abuse treatment, and care for the physical conditions that often accompany these comorbidities, McLellan explained. Such fragmentation leads to poorer outcomes for these patients in all 3 settings. It also may drive up costs because inadequately treated dual-diagnosis patients may be frequently seen in the inpatient psychiatric unit of a hospital or in the emergency department for trauma. However, recent policy developments—the enactment of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the recently passed health reform bill—will vastly expand access to comprehensive addiction and mental health care, according to McLellan. These advances, he said, will benefit both mainstream medicine and specialty care. “When you finally get good integrated care for mental health, substance abuse, and the many physical health problems that can coexist with them, you are going to have quality care and cost containment, McLellan said. Several months ago, McLellan took on a new role as deputy director of the White House Office of National Drug Control Policy (ONDCP), in which he has been working to develop drug-control policies that emphasize treatment along with traditional law enforcement approaches. One effort being advanced by the ONDCP is greater funding for comprehensive mental health and substance abuse treatment at federally funded community health centers. According to McLellan, 50% to 70% of the patients who are treated at these 7000 centers across the country have a substance abuse disorder or mental health diagnosis. Many individuals with comorbid mental illness and substance abuse disorders end up in the criminal justice system. According to the NIDA report, an estimated 75% of the inmates of state and local prisons or jails have such comorbidities, yet little treatment is available in these settings. The NIDA report suggests that improved treatment in prisons and jails may benefit public health and reduce recidivism. The ONDCP is also trying boost substance abuse and mental illness treatment for the more than 5 million persons who are living in communities but are still under court supervision. McLellan estimated that at least half of such individuals have a substance abuse disorder and at least half have another type of mental illness. A key goal is to provide incentives for programs that combine the best practices in monitoring and supervision with the best practices in medication and other therapies for these disorders. “We think it's going to save a lot of money and keep communities safe,” McLellan said. He also encourages specialty mental health and substance abuse clinicians to collaborate with physicians in primary care or fields such as trauma and emergency care. “They ought to be tailoring some of their services to meet the needs of doctors who are dealing with patients in those settings who also need assistance in dealing with concurrent substance abuse and mental illness,” he said. Whatever the treatment setting, Volkow urges physicians to be aware of potential adverse interactions between therapies and to take advantage of therapies that may benefit both conditions in these dually diagnosed patients. For example, bupropion has demonstrated efficacy as both an antidepressant and a smoking cessation therapy. “Being knowledgeable about these common targets can actually enable you to select the optimal treatment,” she said.
JAMA – American Medical Association
Published: May 19, 2010
Keywords: substance abuse,addictive behavior,mental disorders,integrated treatment