Treatment implications and recommendations
The data reviewed paint a picture of anxiety disorder symptoms and substance use locked into a vicious circle of positive feedback. Anxiety symptoms can lead to more use via attempts at self-medication while heavy and long-term use can exacerbate anxiety symptoms. Moreover, treating either disorder alone is unlikely to resolve the untreated problem and runs a high risk of treatment nonresponse and relapse. Therefore, both problems must be treated simultaneously to maximize the chance of good clinical outcomes.
Unfortunately, as Watkins and colleagues24 have noted in a comprehensive review of the relevant literature, little empirical evidence exists to guide treatment in persons with comorbid anxiety and SUDs. In the absence of randomized controlled trials, expert opinion and consensus panels (ie, American Psychiatric Association [APA] guidelines25 and Substance Abuse and Mental Health Services Administration’s Treatment Improvement Protocol Series26) provide rational and experience-based treatment guidelines.
Low and moderate risk of SUDs. Each of the screening instruments comes with its own algorithms describing scores that correspond to low, medium, and high levels of drug/alcohol use and SUD risk. For patients at low risk for SUDs, we recommend that the clinician provide education about the association between anxiety disorders and SUDs, ie, patients with an anxiety disorder are at higher risk for SUDs and can develop SUDs with less overall consumption compared with patients who do not have an anxiety disorder. For patients at medium risk, ie, patients who self-medicate or score in the elevated but not high-risk range of the screening instruments, we recommend that the treating clinician provide a brief inter-vention that involves advice and assistance focused on the substance use (Table 5). If individuals fail to modify their use after the brief intervention, we suggest their risk assessment be elevated to high.
High risk of SUDs. We recommend referral to an SUD specialist for patients at high risk for an SUD based on screening and those at medium risk who failed to modify their substance use following the brief intervention. There are 3 treatment models for comorbid SUD and anxiety disorder: sequential, parallel, and integrated.
The sequential model is no longer the standard for treating comorbid disorders; simultaneous treatment is now recommended.24,27-29 In the parallel model, both the anxiety disorder and SUD are treated simultaneously, usually by 2 clinicians or even at different facilities. A further evolution of the parallel model is the integrated model, with 1 program for treating and monitoring both disorders simultaneously. Integrated treatment is currently considered to be the optimal option; however, such programs are, unfortunately, not available in all areas.
Jake is a 32-year-old who presents for help with his intense anxiety when giving presentations at work. He reports fear of embarrassment in many social situations. The patient is asked about his alcohol use and the pattern of drinking associated with his anxiety symptoms. He replies that he only drinks on the weekends, 6 beers on Fridays and Saturdays when he is faced with socializing with his coworkers. The patient does not report any problems related to his drinking.
This vignette is an example of excessive drinking to self-medicate anxiety. The physician recommends an SSRI for the patient’s social anxiety but also provides feedback about his drinking. This includes telling the patient about the NIAAA drinking guidelines for men being no more than 5 drinks in a single occasion and no more than 14 drinks in a week. The physician would follow this information with a brief intervention such as that shown in Table 5. If the patient is unable to cut back or stop drinking, further discussion and a potential referral are warranted.
Mary is a 42-year-old with a long history of panic attacks for which she has received various medications and psychotherapies. She is taking 4 mg of alprazolam daily but still reports intense ill-defined anxiety as well as panic attacks weekly. She admits to sometimes taking up to 6 mg of alprazolam daily and being preoccupied with her medication and obtaining it. She then runs out early and becomes shaky, sweaty, and more anxious.
This vignette points out some of the complexities in the assessment of persons who present to the psychiatrist’s office. The diagnosis of panic disorder seems clear, but the nature of the ill-defined anxiety needs to be elucidated. Is Mary’s anxiety a consequence of withdrawal from alprazolam or of another comorbid disorder, such as generalized anxiety disorder? Or is it a symptom and not a disorder? It appears that she meets criteria for sedative dependence on the basis of tolerance, withdrawal, loss of control, preoccupation.
Treatment should be directed not only at the panic attacks but also at her dependence on benzodiazepines. Given the moderate-high dose of alprazolam, it is likely that she will need inpatient stabilization for withdrawal management and alternative medication as the beginning of a substance use treatment. An integrated program that has the capacity to simultaneously manage the anxiety as well as the substance dependence is important.
Whether treatments are integrated or parallel, there are some unique concerns when treating anxiety disorders in patients with an SUD or who are in recovery from an SUD. First, because most empirically supported treatments for anxiety disorders were studied in samples that excluded SUDs, it is important to establish that these treatments are also effective in patients with an SUD. On the basis of their meta-analysis of 15 relevant randomized controlled trials, Hobbs and colleagues30 concluded that both cognitive-behavioral therapy and pharmacotherapy for anxiety and depression had significant effects in patients with concurrent SUDs. This suggests that standard anxiety treatments are effective in patients with comorbid SUDs. Table 6 presents approaches based on APA guidelines concerning pharmacotherapies for patients with anxiety disorders who have a current or past comorbid SUD.31
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