Anyone entering the field of addiction treatment will encounter a large number of people who suffer from addiction in combination with psychiatric disorders—what we refer to as comorbidity. As a result, it will be important for addiction counselors to become familiar with the relationship between addiction and comorbid psychiatric conditions, along with the psychotropic medications prescribed to treat them. When people present for addiction treatment, often we don’t know “which came first, the chicken or the egg,” because when people use enough alcohol or other drugs to become addicted, their brain anatomy and chemistry change in ways that can produce psychiatric syndromes like depression, anxiety, mood swings, or even psychosis. On the other hand, sometimes people have a pre-existing depressive, anxiety, or psychotic disorder and use alcohol and other drugs to self-medicate. It’s very common for people who are anxious and/or depressed to use alcohol, marijuana, or other drugs to self-medicate those conditions. One thing for certain is that there is a significant relationship between psychiatric conditions and addiction. People who have been using any form of mind- and mood-altering substance for a substantial period of time will typically report feeling anxious and/or depressed. Often, their psychiatric symptoms are related to their substance use and the brain changes and other real-life consequences it has brought about. A lot of these folks just want to be prescribed an antianxiety agent or antidepressant to relieve their symptoms. My response is to tell them that, “Before we start you on an antidepressant, you have to stop using alcohol, marijuana, cocaine, etc., because that may be the cause of your mood problems. And if your anxiety and/or depression doesn’t go away after you’ve been abstinent for a bit, then we can look at medication options for you.” Psychiatric disorders are syndromes—constellations of symptoms—involving cognition (thinking), mood, and behavior, that lead to significant subjective distress and impairment in social and occupational functioning. All such disorders occur along a continuum: everybody gets anxious from time to time, everyone gets depressed in terms of feeling down or having the blues once in a while, everybody has occasional mood swings, and most everyone has had an occasional bout of insomnia. However, when these experiences become severe enough or are ongoing to the point where they interfere with functioning, then we’re talking about a psychiatric disorder. Certain psychiatric disorders are very common. Data from the 2007 US National Institute of Mental Health’s (NIMH) National Comorbidity Survey Replication Study indicates that the lifetime rate of psychiatric disorder is about 57.4 percent—meaning that over the course of their lifespan, more than half of all people in the US will experience some sort of psychiatric/psychological condition that causes them distress and/or interferes with their functioning(13) The most prevalent psychiatric/psychological illness in US society is anxiety. The estimated lifetime prevalence for an anxiety disorder (including panic disorder, agoraphobia without panic, specific phobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, adult/child separation anxiety disorder) was 31.2 percent. In other words, more than 31 percent of the US population will experience a diagnosable anxiety disorder at some point during their lifespan. The second most prevalent psychiatric condition is depression. As of 2007, the estimated lifetime prevalence for a depressive disorder (major depression or dysthymia) is 19.4 percent. The 2007 data from the National Comorbidity Survey Replication Study further indicates that 32.4 percent of individuals in the United States general population will experience a psychiatric disorder in a given year, with 19 percent experiencing an anxiety disorder, and 8.3 percent experiencing a depressive disorder(14) with all psychiatric syndromes, there is a high prevalence of drug and alcohol use. Alcohol and other drugs change brain functioning and chemistry by altering the balance of certain neurotransmitters. This also creates greater susceptibility to developing various psychiatric symptoms. As I noted above, anxiety, depression, or other psychiatric conditions may also predate the use of substances, and such preexisting psychiatric conditions can produce a situation where a person seeks to self-medicate in order to get some relief from his or her symptoms. He or she may have a primary psychiatric disorder such as generalized anxiety disorder and use alcohol to calm his or her nerves. Someone else who has a depressive disorder feels noticeably better when he or she smokes marijuana or takes opioid pain medications. So it can work in both directions: Substance use makes people more vulnerable to various psychiatric disorders, and psychiatric disorders make people more likely to use and become addicted to alcohol and other drugs. As a result, when someone is using alcohol and/or other drugs, the only way to accurately assess to what extent his or her anxiety, depression, or other psychiatric/psychological symptoms are related to substance use or not, is for him or her to abstain from using for long enough for withdrawal and post-acute withdrawal symptoms to clear. This is really the only way to make an accurate differential diagnosis. Among psychiatric patients, statistics indicate that there is about a 50 percent lifetime prevalence of substance use disorders. The National Alliance on Mental Illness (NAMI) reports that 47 percent of people with schizophrenia also have a substance use problem, which is about four times greater than the general population. And for schizophrenics, comorbid substance use is associated with higher rates of homelessness, noncompliance, medical illness, and violence. The statistics are strikingly similar for those diagnosed with bipolar disorder: more than half of them use alcohol and other drugs, predominantly stimulants. Substance use can reduce the effectiveness of treatment for psychiatric disorders and psychiatric disorders also reduce the effectiveness of addiction treatment by decreasing the likelihood that patients will follow their recommended treatment and aftercare plans. For instance, substance use compounds the problems of people with bipolar disorder. Individuals with this comorbidity get less benefit from their mood-disorder treatment, recover more slowly from mood swings, spend more time in hospitals, and are more prone to committing suicide. They also are less responsive to drug use treatment than persons who are not comorbid(15). This high incidence of comorbidity is why we cannot effectively treat the psychiatric illness without also treating the addiction. We need to address both concurrently. It’s important for addiction therapists to understand the distinctions, not only between different diagnostic categories, but also among different subcategories. For example, there are critical differences between a bipolar I disorder and bipolar II, even though they are both “bipolar disorders.” Bipolar I (once known as manic-depressive disorder) involves the classic alternating or cycling between phases of intense mania and deep depression. It is the more severe type in which people can have psychotic episodes and wind up hospitalized psychiatrically. Bipolar II is different in that the symptoms are primarily depressive. There is no extreme manic phase or “high.” Attention deficit hyperactivity disorder is characterized by a persistent pattern of inattention and/or hyperactivity. According to the National Institute of Drug use, estimates of up to 50 percent of patients with ADHD use alcohol or other drugs. Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that’s triggered by directly experiencing or witnessing a terrifying, or as the name suggests, traumatic event. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable intrusive thoughts about the event. Such traumatic events include natural disasters like earthquakes or floods, the ravages of war, being in a car or another kind of accident, being a victim of crime or physical or sexual assault or use. A great many veterans returning from the wars in Afghanistan and Iraq suffer from PTSD. Post-traumatic stress often precedes substance use disorders, and it is not unusual for those with PTSD to numb themselves or otherwise self-medicate through substance use. Statistics indicate a significant correlation between addiction and physical and sexual use, especially in women. Anyone involved in addiction counseling for very long hears horrific stories about how many of the addicted persons they work with were physically and sexually used as children or teenagers. Often, they continue to be subjected to use and assault as adults. Combinations of psychotherapies and behavioral and pharmacological interventions offered by psychotropic medication provide the most effective treatment for addiction and comorbid psychiatric disorders(16). Psychotropic medications work in the brain and are used to treat the disturbances in thought, mood, and behavior associated with psychiatric disorders. As covered here, they include antidepressants, antianxiety medications (sometimes called anxiolytics),psychostimulant medications used for ADD/ADHD, mood stabilizers, and antipsychotics, sometimes called neuroleptics. The benefit of psychotropic medications is that they assist with biologically based disorders by decreasing symptoms that interfere with people’s ability to function. Negative symptoms are thoughts, feelings, or behaviors that are normally present, that are absent or diminished in a person with a psychiatric disorder. examples of negative symptoms are social withdrawal, apathy (decreased motivation), poverty of speech (brief replies), inability to experience pleasure (anhedonia), limited emotional expression, and deficits in attention/concentration and/or behavioral control. Psychotropic medications have the potential to increase the effectiveness of the other psychotherapeutic approaches. 13 http://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_Prevalence_estimates.pdf. (accessed February 15, 2013). 14 http://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_12-month_Prevalence_estimates.pdf. (accessed February 15, 2013). 15 National Institute on Drug use, “Attention to bipolar disorder strengthens substance use treatment”2010. http://www.druguse.gov/news-events/nida-notes/2010/04/attention-to-bipolar-disorder-strengthens- substance-use-treatment (accessed February 18, 2013). 16 Thomas A. Kelly, Dennis C. Daley, and Antoine B. Douaihy, “Treatment of substance abusing patients with comorbid psychiatric disorders,” Addictive Behaviors 37, vol. 1 (2012): 11–24. http://www.ncbi.nlm.nih.gov/ pubmed/21981788 (accessed February 25, 2013). This blog post is an excerpt from The therapist’s Guide to Addiction Medicine – A Handbook for Addiction Counselors and Therapists – by Barry Solof, MD, FASAM; Published by Central Recovery Press (CRP).