When an individual with the disease of addiction is also suffering from a mental illness or disorder, they are said to have comorbidity or co-occurring disorders. The interaction between the two illnesses can often lead to additional complications in treating the patient as a whole. It can be difficult for the clinician to determine which illness to treat first, or to treat both at the same time. To further complicate matters, a different type of clinician is often required when treating each facet of illness from which the patient is suffering.
Studies confirm that addicts are much more likely to suffer from comorbidity than the general population. It is unclear as to whether drug use causes the mental illness or worsens the pre-existing mental illness, but it is clear that a person vulnerable to one type of brain disease may also be susceptible to another. This is because the same neuro-pathways, chemicals, neurotransmitters, and molecules in the brain are effected by any brain disease. There is An unclear genetic component to the predisposition of addiction and mental illness as well.
Drug use can be a form of self-medication for many individuals with mental illness. For an individual with schizophrenia, smoking seems to help them experience calmness. For an individual with major depressive disorder, certain drugs can stimulate the pleasure center of the brain which helps to elevate mood. Conversely, drug use is linked to symptoms of mental illness. Stimulants can cause panic attacks, anxiety, manic episodes and sleep disorders. Methamphetamine can cause involuntary hallucinations. Heavy marijuana users exhibit signs of psychosis.
When treating addiction, it is often necessary for the patient to remain abstinent for thirty to ninety days before treatment for a mental illness can commence. This is because some of the symptoms of mental illness are mimicked by the substance use and continue into post-acute withdrawal. Once a definite diagnosis is reached, treatment for both the addiction and the mental disorder is recommended to take place concurrently.
Treating comorbidity is very often more difficult than treating just one illness. Patients suffering from symptoms of comorbidity are usually more resistant to treatment, have symptoms that are more persistent, and have more severe symptoms as well. As a result, it is critical to adjust expectations for treatment results in patients with comorbidity.
There are a multitude of treatment approaches that are effective in treating comorbid patients. The National Institute on Drug Abuse (NIDA) publishes the following information on the treatment of comorbidity:
Therapeutic Communities (TCs)
TCs focus on the “resocialization” of the individual and use broad-based community programs as active components of treatment. TCs are particularly well suited to deal with criminal justice inmates, individuals with vocational deficits, women who need special protections from harsh social environments, vulnerable or neglected youth, and homeless individuals. In addition, some evidence suggests the utility of incorporating TCs for adolescents who have been in treatment for substance abuse and related problems.
Assertive Community Treatment (ACT)
ACT programs integrate the behavioral treatment of other severe mental disorders, such as schizophrenia, and co-occurring substance use disorders. ACT is differentiated from other forms of case management through factors such as a smaller caseload size, team management, outreach emphasis, a highly individualized approach, and an assertive approach to maintaining contact with patients.
Dialectical Behavior Therapy (DBT)
DBT is designed specifically to reduce self-harm behaviors (such as self-mutilation and suicidal attempts, thoughts, or urges) and drug abuse. It is one of the few treatments that is effective for individuals who meet the criteria for borderline personality disorder.
Exposure therapy is a behavioral treatment for some anxiety disorders (phobias, PTSD) that involves repeated exposure to or confrontation with a feared situation, object, traumatic event, or memory. This exposure can be real, visualized, or simulated, and always is contained in a controlled therapeutic environment. The goal is to desensitize patients to the triggering stimuli and help them learn to cope, eventually reducing or even eliminating symptoms. Several studies suggest that exposure therapy may be helpful for individuals with comorbid PTSD and cocaine addiction, although retention in treatment is difficult.
Integrated Group Therapy (IGT)
IGT is a new treatment developed specifically for patients with bipolar disorder and drug addiction, designed to address both problems simultaneously.
Progress in the treatment of a patient with comorbidity can be slow and cumbersome. There are often periods of considerable insight and improvement, followed by periods of regression and relapse. This can be frustrating for the patient as well as the family members of the patient. It can be difficult to remain motivated when disappointments occur and it is necessary for all parties involved to stay motivated in order to reinforce what is learned in treatment. It is helpful to develop treatment plans that include specific goals, and to monitor progress toward those goals. It is imperative that the treatment plan is revisited regularly for modifications as comorbidity often involves significant shifts in treatment.
Reinforcement of progress toward treatment goals is the best way to create momentum and motivation in the treatment of a patient with co-occurring disorders. Goals should be well defined and broken down into small incremental successes toward a larger objective. Each time a milestone is reached, the achievement should be celebrated and reinforced; providing the patient with the needed confidence to continue with their hard work. For example, a patient with vocational problems due to drug use and bipolar 1 disorder has been unable to retain a job for more than a few weeks at a time. A vocational objective may be long-term employment. The goals moving toward long-term employment may include:
- Revising resume
- Researching potential employers
- Managing coping mechanisms for stressors associated with contacting potential employers
- Rehearsing how to communicate with potential employers on the phone and internet
- Reviewing how to dress for success
- Purchasing or putting together the appropriate clothing for an interview
- Contacting potential employers
- Completing employment applications
- Managing coping mechanisms for stressors associated with interviews
- Handing in employment applications
- Rehearsing interviews and building interview skills
- Managing sleep patterns
- Managing coping mechanisms for stressors associated with authority figures
- Employment interviews
- Managing coping mechanisms for stressors associated with responsibility
- Managing coping mechanisms for stressors associated with interpersonal contact and communication
- Time management for arrival on time to the workplace
- Beginning work
- Managing coping mechanisms for stressors associated with guilt and shame
- Asking for performance feedback
By being very diligent about identifying and carrying out the small steps in the progress of the patient, the patient is more likely to succeed in the long-term. If there are periods of regression and/or relapse, the goals are re-written to reflect the point at which the patient is starting again.
Above all else, the patient and the family members need to keep appropriate expectations. All parties involved need to be looking for overall progress, and avoid the trap of expecting too much too quickly. With time comes healing and recovery.
By Andrew Martin, MBA, LAADC, SAP, CA-CCS