The co-occurrence of substance abuse and psychiatric disorders is a complex and common phenomenon. The National Institute of Mental Health Epidemiologic Catchment Area (ECA) study and the National Comorbidity Study (NCS) are two large epidemiological surveys that have evaluated the prevalence of comorbid psychiatric and substance use disorders in community samples. In the ECA study, 45% of individuals with alcohol use disorders had at least one co-occurring psychiatric disorder (Regier et al. 1990). Likewise, in the NCS, 78% of alcohol-dependent men and 86% of alcohol-dependent women met lifetime criteria for another psychiatric disorder, including drug dependence (Kessler et al. 1996). The co-occurrence of psychiatric and alcohol use disorders is clinically important because comorbidity has a negative impact on the course, treatment outcome, and prognosis of both syndromes.
The accurate diagnosis and differentiation between substance-induced states and primary psychiatric diagnoses are two of the more difficult tasks in assessing patients with co-occurring psychiatric symptoms and substance use disorders. Clinicians often differentiate substance-induced transient symptoms from psychiatric illness through observation during a period of abstinence. However, the duration of abstinence necessary for accurate diagnosis should be based on both the diagnosis being assessed and the substance used. Sustained psychiatric symptoms during lengthy periods of abstinence, a family history of the particular psychiatric disorder, and the onset of psychiatric symptoms before the onset of substance abuse and dependence all suggest a primary psychiatric illness.
Although the treatments for psychiatric and substance use disorders have largely consisted of separate clinical services, the integration of services is paramount to the optimal treatment of individuals with
comorbid conditions. Such programs often include a mix of group and individual therapy. CBTs are among the most efficacious treatments for anxiety disorders and substance use disorders (Anton et al. 1999). Brown et al. (1997) demonstrated that alcoholic persons with depressive symptoms had improved outcomes at 3- and 6-month follow-up visits after treatment with CBT for depression, compared with a control group given treatment in the form of relaxation training. Individuals with comorbid psychiatric and substance use disorders can also benefit from participation in 12-step groups such as Alcoholics Anonymous and Narcotics Anonymous.
The ideal approach to the pharmacological treatment of comorbid conditions is to use an agent that has no abuse potential, is safe and well tolerated, and may be efficacious for both disorders. Data support the use of selective serotonin reuptake inhibitor (SSRI) agents for the pharmacotherapeutic treatment of comorbid alcohol dependence and major depression. Higher doses of SSRIs and tricyclic
antidepressants may be required because of the possibility that alcohol use has induced hepatic
microsomal activity. The use of SSRIs in the area of subtyping alcoholics shows promise, but much work remains to be done (Kranzler et al. 1996; Pettinati et al. 2000). Although lithium is accepted as the gold-standard agent in the treatment of bipolar disorder, anticonvulsant agents have shown some promise in the treatment of substance use disorders and comorbid bipolar and substance use disorders (Myrick et al. 2004). Research investigating the use of psychiatric medications in combination with alcohol-treatment medications such as naltrexone and acamprosate would be useful.
Adolescents
Alcohol is the most the common substance of abuse among adolescents. In 2005, 47% of twelfth graders reported past-30-days drinking and 29.2% reported binge drinking (five or more drinks in a row, per occasion) within the past 2 weeks (Johnston et al. 2006). Diagnostic criteria for alcohol use disorders are based on adult symptom patterns, which may not fit for some heavy-drinking teenagers. The diagnostic criteria of preoccupation, loss of control, and reckless behavior while using can occur in teenagers, but medical problems and severe withdrawal are unlikely (Brown and D'Amico 2001). When evaluating adolescents with possible alcohol use disorders, educational status, family functioning, peer relationships, legal status, and use of free time should be assessed, in addition to direct questions about the use of alcohol and other drugs and possible psychiatric disorders. Investigating areas of academic performance, school attendance, disciplinary problems, and any history of abuse can be particularly important because it helps the practitioner ascertain the adolescent's risk of an alcohol use disorder. There is a high level of co-occurrence of substance use and other psychiatric disorders in adolescents.
Psychosocial treatments for alcohol use disorders in adolescents should be adapted for this specific population. If at all possible, family participation should be viewed as a prerequisite for successful treatment for any adolescent with a substance use disorder. Motivational therapy, CBT, behavioral therapies (including operant-conditioning methods as well as behavioral contingency contracts and parent management training), family therapy, and 12-step approaches may all be useful options. In employing 12-step approaches, it is important to help the family identify a support group that is geared specifically toward adolescents. Multisystemic therapy involves working with teenagers, parents, schools, community resources, and peers to decrease problem behaviors (Henggeler et al. 1995). As with adults, the aim of pharmacotherapy in adolescents with substance use disorders includes
detoxification, interfering with the physiological and subjective effects of the substance, and treatment of co-occurring psychiatric disorders. A small, open-label trial of naltrexone in adolescents found that it was well tolerated and reduced craving and drinking among adolescents who were dependent on alcohol (Deas et al. 2005).
Women
Differences have been identified in the incidence, development, and consequences of alcohol
dependence in women as compared with men; women more often drink alone, binge less, have more
regular drinking patterns, and drink smaller quantities. For women in relationships, drinking patterns are more likely to match that of their significant others. After equivalent doses of alcohol, women have been shown to have higher blood ethanol levels than men. Likely contributors to this include lower levels of alcohol dehydrogenase in the gastric mucosa and livers of women compared with men, as well as the lower adjusted total body water content and smaller volume of distribution in women (Frezza et al. 1990).
The faster progression from first drink to significant problems with alcohol in women as compared with men has been termed the telescoping effect (Frezza et al. 1990). Women reach criteria for alcohol dependence from onset of drinking more quickly than men and progress to liver disease with lower levels of drinking over a shorter period of time than do men. In addition, women who develop cirrhosis from alcohol dependence have a higher rate of mortality than their male counterparts. Women's risk of breast cancer is also increased by moderate to heavy alcohol consumption.
Alcohol use disorders in women can lead to sexual dysfunction, menstrual cycle abnormalities, and amenorrhea (Blume and Russell 2001). Alcohol may also increase the risk of spontaneous abortion. Fetal alcohol syndrome, resulting from heavy use of alcohol during pregnancy, is characterized by growth deficiencies, facial abnormalities, and significant impairments in the neurodevelopment of the fetus (Jones and Smith 1973). In addition, studies suggest that even low to moderate levels of drinking during pregnancy are associated with alcohol-related birth defects.
Women with alcohol use disorders are more likely to present for treatment of other problems, such as marital or relationship difficulties, physical illness, or emotional problems (Weisner and Schmidt 1992). Related to this, they are more likely to seek treatment in psychiatric or primary care settings than in traditional substance disorders treatment programs (Beckman and Kocel 1982). Estimates indicate that women make up approximately 25% of patients in traditional treatment centers for alcohol dependence in the United States (U.S. Department of Health and Human Services 1990). It is important to recognize potential gender-specific barriers that may have an impact on treatment initiation and completion. Such barriers include lack of gender and cultural appropriateness in program content, fear of legal
consequences (particularly loss of child custody), lack of child care and transportation, inadequate or no health insurance coverage, caretaker roles for dependent family members, and societal intolerance and stigmatization of substance-dependent women (Chasnoff 1991). Some evidence suggests that gender- specific services can improve treatment retention, substance use outcomes, and possibly psychosocial functioning in women when compared with traditional mixed-gender programs, but further research is warranted (Brady and Ashley 2005; Greenfield et al. 2007).