1	Comorbid Substance Use and Psychiatric Disorders Kim Mueser, Ph.D. Robert E. Drake, M.D., Ph.D. Mark McGovern, Ph.D. Win Turner, Ph.D. Dartmouth Medical School NH-Dartmouth Psychiatric Research Center
2	Overview Prevalence of comorbid disorders Effects of comorbidity on course of disorders Models for explaining excessive comorbidity Treatment approaches to comorbid disorder Comorbidity in youth
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4	Rates of Lifetime Substance Use Disorder (SUD) among Recently Admitted Psychiatric Inpatients (N=325) (Mueser et al., 2000)
5	Prevalence of mental illness in alcohol disorder samples In community, 24.4% have mental illness In institutions, 55% have mental illness In substance abuse treatment, 65% have mental illness
6	Major Subgroups of Comorbid Clients Severely mentally ill - psychotic Frequently abuse moderate amounts of substances Small amounts of substance use trigger negative consequences Anxiety and/or depression Substance use can cause or worsen symptoms
7	"Frequently abuse moderate to high..." Frequently abuse moderate to high amounts of substances Personality Disorders Antisocial & borderline most common Frequently abuse high amounts of substances
8	Client Factors Influencing Prevalence of Substance Use Disorders in Severe Mental Illness Higher Rates Males Younger Lower education Single or never married Good premorbid functioning History of childhood conduct disorder Antisocial personality disorder Higher affective symptoms Family history
9	Common Consequences of Substance Abuse in Clients with Severe Mental Illness Relapse and re-hospitalization Financial problems Family burden Housing instability and homelessness Non-compliance with treatment Violence Suicide Legal problems Prostitution Health problems Infectious disease risky behaviors
10	Psychiatric Comorbidity Worsens Outcome of Substance Abuse Treatment Psychiatric illness severity predicts less improvement in substance abuse Relationships of specific disorders to substance abuse outcome unclear Association between ASPD and worse outcome attenuated by controlling for initial level of substance abuse severity
11	Models of Comorbidity Berkson’s Fallacy Secondary mental illness models Secondary substance abuse models Common factor models Bi-directional models
12	Secondary Mental Illness Models: Depression Substance abuse results in losses that can lead to depression Depression frequently remits following substance abuse treatment (secondary effects or non-specific response to depression?) Persistent depression in subgroup, but unclear etiological relationship to substance abuse
13	Secondary Mental Illness Models: ASPD Active substance abuse can lead to antisocial behaviors If these behaviors were absent before substance use, they usually remit when substance use does Vaillant: “Are we putting the cart before the horse…”
14	Secondary Mental Illness Models: Schizophrenia Chronic stimulant use as precipitant of schizophrenia: lack of replication of early findings Hallucinogen abuse as precipitant of long-term psychosis: clients tend to have relatives with psychosis Cannabis prospectively predicts onset of schizophrenia: 1) can’t explain stable rate of schizophrenia following rise in cannabis use; 2) may be accounted for by early prodrome involving mood disturbance
15	Secondary Mental Illness Models: Bipolar Disorder Bipolar disorder hypothesized to follow substance abuse due to behavioral sensitization or neuronal kindling Bipolar disorder following alcoholism associated with lower rates of family bipolar disorder & more rapid recovery Limited data testing this hypothesis
16	Secondary Substance Abuse Models Self-medication General dysphoria Super-sensitivity Secondary psychosocial effects
17	Self-Medication Hypothesis Substance type unrelated to specific symptoms or diagnosis Symptom severity unrelated to substance abuse Clients usually don’t report substances reduce symptoms Exception: PTSD, where alcohol abuse follows onset of disorder, & is reported as coping strategy for specific arousal symptoms (sleep)
18	General Dysphoria Hypothesis Dysphoria common across mental disorders Some evidence linking trait dysphoria to substance abuse in mental illness Inconsistent findings suggesting link between depression and substance abuse in severe mental illness
19	"Super-sensitivity Model" Super-sensitivity Model Biological sensitivity increases vulnerability to effects of substances Smaller amounts of substances result in problems “Normal” substance use is problematic for clients with severe mental illness but not in general population Sensitivity to substances, rather than high amounts of use, makes many clients with severe mental illness different from general population
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21	Status of Moderate Drinkers with Schizophrenia 4 - 7 Years Later (N=45)
22	"Support for Super-sensitivity Model" Support for Super-sensitivity Model Dual disorder clients less likely to develop physical dependence on substances Standard measures of substance abuse are less sensitive in clients with severe mental illness Clients are more sensitive to effects of small amounts of substances Few clients are able to sustain “moderate” use without impairment Super-sensitivity accounts for some increased comorbidity
23	Secondary Psychosocial Effects Model Psychosocial consequences of mental illness increase vulnerability to substance abuse (limited research): Cognitive impairment Social extrusion Poverty Increased sensitivity to stress Free time/no work, parenting responsibilities
24	Common Factor Models Genetic vulnerability Cognitive impairment Social disadvantages ASPD
25	CD, ASPD, and Recurrent Substance Abuse Disorders
26	Summary of Models of Comorbidity Secondary mental illness: limited support across disorders, may precipitate earlier age onset of psychosis & some cases depression Secondary substance abuse: support for supersensitivity model, marginal support for dysphoria hypothesis Common factors: support for ASPD
27	It’s not All Self-Medication: Motives for Using Substances Related to Mental Illness Coping or escape from persistent symptoms Social facilitation Leisure and recreation Structure and meaning in life
28	Treatment Models Integrated dual disorder treatment The quadrant model
29	Treatment Barriers Historical division of service and training Sequential and parallel treatments Organizational and categorical funding barriers in the public sector Eligibility limits, benefit limits, and payment limits in the private sector
30	Integrated Treatment Mental health and substance abuse treatment Delivered concurrently By the same team or group of clinicians Within the same program The burden of integration is on the clinicians
31	Other Features of Dual Disorder Programs Assertive outreach Stage-wise treatment: engagement, persuasion, active treatment, and relapse prevention Long-term commitment Comprehensive treatment Reduction of negative consequences
32	Research on Integrated Treatment (IT) 26+ RCT or quasi-experimental studies of IT (reviewed by Drake et al., 2004; Mueser et al., in press; Brunette et al., in press) 3/4 studies of brief motivational interviewing interventions showed positive effects 6/7 studies found group intervention better than 12-step or standard care
33	Research on IT (Cont.) Family intervention: no RCTs examining family treatment alone Comprehensive IT: 2 RCT & 1 quasi-exp. study favor comp. IT over treatment as usual Intensity: more intensive IT produces slightly better outcomes (e.g., Drake et al., 1998)
34	Fidelity to IT Model Improves Outcome
35	Integrated Treatment for Less Severe Psychiatric Disorders A few studies of integrated mental health care in substance abuse treatment settings produced mixed results Support for integration lacking at this time (e.g., anxiety disorders, depression,
36	Quadrant Model Different subgroups based on severity of each disorder proposed to have different treatment needs Draws attention to wide diversity of DD clients, treatment settings, and needs Problematic because categories do not correspond to valid treatment approaches, clients shift categories over time, clinical groups do not appear consistently in the service settings, clinicians in settings face diverse client groups Lack empirical support
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38	Dual Disorders in Youth Very high rates of comorbidity (60-80%) Conduct disorder, ADHD, anxiety, depression Often present in substance abuse treatment settings but involved in multiple systems of care Trauma ubiquitous
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40	Treatment of Youth Lack of controlled research, but common treatment elements include: Intensive services Home-based care Family involvement Case management Psychiatrist Stage-wise intervention
41	Principles Co-occurring disorders are the rule not the exception Co-occurring disorders worsen course of illness & treatment response compared to either disorder alone Multiple models proposed to explain excessive comorbidity, & while some data support different models for different subgroups, no model accounts for excessive comobidity even within a particular subgroup Traditional approaches to treating DD has met with limited success
42	Principles (Cont.) Integrated treatment models have support for SMI but not other disorders Youth with emotional or substance use problems have high rates of DD, which are often combined with multiple other life challenges, including trauma, family instability, school problems, and involvement in the juvenile justice system The failure to treat emotional problems soon after they develop in youth represents a significant missed opportunity for the prevention of subsequent substance use problems
43	Principles (Cont.) Treatment programs that address both emotional and substance abuse, and that combine cognitive-behavioral approaches with family work and collaboration across multiple systems of care for youth have shown promise for improving outcomes of co-occurring disorders More work is needed to be responsive to treatment needs of DD youth and adults presenting at diverse settings
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45	3 Questions Does anyone really think it’s a good idea to separate clinical training, funding, & services into mental health & substance abuse categories? Could treatment/rehabilitation efforts targeting presumed cognitive, affective, & social correlates of delay discounting in mental illness prevent or more effectively treat substance abuse in these individuals? How do we teach clinicians how to individualize treatment to motivational stage & to address personal motives for using substances in a world of treatment packages?