CME credit for this article is now expired. It appears here for informational purposes only.
At the end of this article, readers should be able to:
1. Delineate evidence-based principles of successful assessment and treatment.
2. Translate these principles into applications for real-world practice.
3. Develop treatment strategies for patients who have comorbid mental illness and substance use disorder.
During the past 10 to 15 years, psychiatrists have increasingly recognized the importance of successfully engaging and treating individuals with comorbid psychiatric and substance use disorders. National epidemiological studies and surveys have clearly indicated that “co-occurring disorders are an expectation, not an exception.”1 In particular, data from the Epidemiology Catchment Area survey showed that of people living in the community, 55% of those with schizophrenia and 62% of those with bipolar disorder had a lifetime diagnosis of substance use disorder.2
The National Comorbidity Survey replicated and expanded these results, and findings of high prevalence of comorbid mental illness and substance use disorders have been further demonstrated in more recent national epidemiological reports.3-6 Epidemiological studies have indicated higher odds ratios for comorbid substance use in adults and adolescents with nearly every psychiatric disorder, compared with those for the general population. Conversely, individuals (adults and adolescents) with diagnosed substance use disorders have higher odds of having a comorbid mental health condition than individuals with no substance use disorder. Furthermore, findings indicate a high prevalence of substance use disorders comorbid with trauma-related pathology.7
In the past decade, there has been increasing research on evidence-based integrated treatment approaches for individuals with comorbid disorders. This research includes specific program models, such as Integrated Dual Disorder Treatment, as well as a range of integrated practices and approaches based on that model.8 These approaches have been condensed into instructions for integrated practice for clinicians and include an array of guidelines (eg, assessment, service planning, treatment).9,10 On the basis of this and other research, the Comprehensive, Continuous, Integrated System of Care incorporates universal integrated practice (termed “co-occurring capability”) as a fundamental system design feature and utilizes research-based principles that inform integrated practice.11,12
There has also been a growing body of research on the effectiveness of psychotropic medication for mental illnesses in individuals with psychiatric disorders and co-occurring active substance use. Whereas active substance users were previously excluded from psychopharmacological research, resulting in limited data on the effectiveness of psychotropic medications in this population, current research makes it clear that active psychopharmacological intervention for mental illness produces significantly better treatment outcomes in these individuals, even when active substance use continues. It is now best practice for psychiatric prescribers to work within an integrated treatment framework, in which appropriately matched psychopharmacological and non-psychopharmacological interventions for both mental illness and substance use disorders are integrated into patient care.
In addition, as understanding of the “brain disorder of addiction” has increased, there has been a steady expansion of pharmacological options specific for treatment of substance use disorders.13 The previously limited armamentarium of psychopharmacology for addiction has been expanded to include an array of anticraving agents that directly intervene in the neurotransmitter mechanisms that support continuing addiction.14 In addition, opiate maintenance treatment, formerly restricted to licensed methadone programs, can now be provided more readily in office-based settings by practitioners who prescribe buprenorphine. Many common psychotropic medications are being shown to also have a potential direct effect on improving substance use disorders. For nicotine dependence, the most prevalent and most potentially lethal of comorbid substance use disorders, there are a range of psychopharmacological agents that have specific and potentially lifesaving indications.
Principles of treatment
The psychopharmacological principles outlined in this article are based on 3 publications:
• The Centers for Mental Health Services (CMHS) Managed Care Initiative Report15 that includes treatment principles and practice guidelines (including psychopharmacology guidelines) for individuals with co-occurring psychiatric and substance use disorders
• An updated version of the CMHS Managed Care Initiative Report co-occurring disorder psychopharmacology practice guidelines that incorporates more current information16
• An even more recent document issued by the Substance Abuse and Mental Health Services Administration that references and builds on the previous work17
Because comorbidity is highly prevalent, all practicing psychiatrists are likely to see patients with co-occurring mental illness and substance use disorders, including patients with active use. The first principle of treatment is therefore to purposefully welcome these individuals—who are most likely to be at risk for poorer outcomes if not successfully engaged in care. A welcoming approach facilitates the creation of an empathic, hopeful relationship, screening for co-occurring substance use, building trust to allow the patient to share information, and working in partnership with the patient over time to make progress on both disorders.12,15
Kenneth Minkoff, MD, has no disclosures to report.
Mark J. Albanese, MD (peer/content reviewer), has no disclosures to report.
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