Substance use disorder (SUD) plays a prominent role in the epidemiology, cause, and course of mental illness. It is estimated that 9.1% of our population, or more than 22 million Americans, have SUD; however, only 10% of these persons receive treatment. The incidence of SUD in persons with mental illness (21.3%) is significantly greater than for those without mental illness (7.7%). Of the more than 5 million Americans with comorbid mental illness and SUD, fewer than half received treatment at either a specialty mental health or substance abuse treatment facility. Only 8.5% received treatment for both mental illness and SUD; the rest received either one or the other.1 These statistics underscore the prevalence of comorbid mental illness and SUD and clearly show that the majority of patients are currently not receiving treatment for these disorders.
There are a number of reasons why patients with comorbid disorders do not receive necessary care. These include lack of treatment access, cost of treatment, stigma, separation of care for mental illness and SUD, a medical care system that de-emphasizes the importance of recognizing and treating SUD, and a medical education system that devotes very little time to this area. This Special Report addresses the latter problem by providing a series of 5 excellent articles that cover a wide range of issues in comorbid disorders.
We have selected topic areas of importance to practicing psychiatrists, including a pair of articles, one by Emma Barkus and the other by Ismene Petrakis, on the neurobiology of psychotic and substance use disorders, as well as pharmacologic management of psychosis in those with comorbid SUD. These articles lay the framework that supports the use of atypical antipsychotics in this population while also pointing out the need for continued research.
A timely and critically important article on the treatment of acute and chronic pain in the patient with SUD is presented by Penelope Zeigler. This topic is arguably one of the most difficult problems faced by physicians, and because of the epidemic of prescription opioid abuse and dependence in the United States, it is one of growing importance.1
Some of the most challenging patients seen in psychiatry today are those with comorbid borderline personality disorder and SUD. Feske, Soloff, and Tarter present a state-of-the-art discussion on the relationship between borderline personality disorder and substance abuse, as well as a succinct discussion of promising therapeutic interventions.
And finally, the article on differential effects of substance abuse in women by Back, Contini, and Brady is an excellent review that brings together a wide literature to make a strong case for gender-based differences in vulnerability to substances and their effect on disease course.
This series of articles provides an evidence-based foundation for some of the more difficult areas of psychiatry today and should assist the practicing clinician in addressing these challenging problems.