1. health and fitness
2. disorders

2004
Addiction and Mental Health:
Issues in Prevalence, Symptoms, and
Treatment of Co-occurring Addiction
and Psychiatric Disorders
Published By Caron Treatment Centers
www.caron.org
About Caron Treatment Centers…
Caron Treatment Centers is a leading provider of
addiction treatment services in the fight against
chemical dependency. Caron uses a comprehensive
treatment approach incorporating spirituality, the
family, and current medical/psychological
interventions to help those affected by addiction
begin a life of recovery. Since its founding in 1957,
Caron has pioneered the concept of residential
codependency treatment, and currently offers
expertise in treatment services for adults, young
adults and adolescents. These services include:
early intervention, medical evaluation and
detoxification, primary and extended residential
treatment, relapse treatment, outpatient treatment
and family education.
Caron has responded to the continued demand for
addiction treatment services by offering facilities
in Wernersville, Pennsylvania, and Boca Raton,
Florida. Caron also has regional offices in New
York City and Philadelphia.
Caron’s mission is “to provide an enlightened, caring
treatment community in which all those affected by
alcoholism or other drug addiction may begin a new life.”
Table of Contents
Section I: Prevalence and Risk Factors . . . .4
Section III: Addiction and
Mental Health Treatment . . . . . . . . . . . . . . .15
Prevalence of Co-Occurring
Service Delivery Disconnections . . . . . . . . . . . . . . . . .15
Addiction and Psychiatric Disorders . . . . . . . . . . . . .4
Diagnostic Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Gender Differences . . . . . . . . . . . . . . . . . . . . . . . . .5
Clinician Expertise . . . . . . . . . . . . . . . . . . . . . . . .15
Adolescent Issues . . . . . . . . . . . . . . . . . . . . . . . . . .6
Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . .16
Risk Factors for Addiction and Relapse
When Psychiatric Disorders Are Present . . . . . . . . . . . .6
Diagnosis of Co-Occurring Disorders . . . . . . . . . .16
Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Treatment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Sequence of Occurrence . . . . . . . . . . . . . . . . . . . .6
Treatment Adherence . . . . . . . . . . . . . . . . . . . . . .17
Psychiatric Risk Factors . . . . . . . . . . . . . . . . . . . . . .7
Breaking the Cycle of Addiction
and Psychiatric Illness . . . . . . . . . . . . . . . . . . . . . .17
Relapse Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Pharmacological Treatment . . . . . . . . . . . . . . . . .18
Section II: Common Co-Occurring
Psychiatric Disorders . . . . . . . . . . . . . . . . . . . .8
Integrating Psychiatric and Addiction
Treatment Approaches . . . . . . . . . . . . . . . . . . . . . . . .18
Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Integrated Treatment . . . . . . . . . . . . . . . . . . . . . .18
Depressive Disorders . . . . . . . . . . . . . . . . . . . . . . .9
Concurrent Treatment . . . . . . . . . . . . . . . . . . . . .19
Bipolar Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .9
Sequential Treatment . . . . . . . . . . . . . . . . . . . . . .20
Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Continuing Integrated Care . . . . . . . . . . . . . . . . .20
Post-Traumatic Stress Disorder . . . . . . . . . . . . . . .10
Recommendations for Treatment . . . . . . . . . . . . . . . .21
Disruptive Behavior Disorders . . . . . . . . . . . . . . . . . . .10
Final Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Attention Deficit Hyperactivity Disorders . . . . . . .11
Section IV: Addiction and Mental Health
Treatment at the Caron Foundation . . . . . . .22
Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Psychotic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .13
Antisocial Personality . . . . . . . . . . . . . . . . . . . . . .13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Borderline Personality . . . . . . . . . . . . . . . . . . . . . .14
1
Forward
comprehensive, and sustained treatment can affect the
better serve individuals suffering from substance use
development of comorbid conditions.
disorders. State of the art addiction treatment
Frances R. Levin, M.D. and John J. Mariani, M.D.
The fourth challenge is the optimal delivery of
identifies those individuals suffering from co-occurring
treatment services. Historically, substance abuse
psychiatric conditions and provides services in an
treatment and psychiatric care were delivered in
integrated approach. Providing this optimal level of
he identification and treatment of co-
in individuals whose psychiatric symptoms are likely
separate settings, with little coordination or
care is dependent on a philosophy that addiction
occurring psychiatric disorders is the new
secondary to substance use, the emphasis will be on
communication. Moreover, in the past, substance
treatment is a comprehensive and complex service,
frontier of addiction research and
achieving abstinence, while in patients with evidence
abuse treatment programs routinely excluded patients
which requires multi-disciplinary expertise and
treatment. Over the past 15 years our understanding of
of an independent psychiatric disorder, symptom
with psychiatric illness and psychiatric clinics would
coordination. The report that follows provides a
the prevalence of co-occurring psychiatric conditions
specific treatment will likely be indicated from the
refuse to treat patients with substance use disorders
comprehensive overview of addiction and co-
in individuals who have substance use disorders has
outset. Helping the patient better understand their
who were not abstinent. This fragmented system of
occurring psychiatric conditions, and then details the
increased dramatically. We now know that psychiatric
diagnosis is critical to the ultimate success of the
care poorly served patients. At present, while it may
Caron Foundation’s experience with this population
disorders are common in patients suffering from
treatment plan.
not be feasible for every treatment program to offer a
and their approach to providing individualized care.
full menu of substance abuse and psychiatric services,
The description of the Caron Foundation’s integrated
T
The second challenge in better meeting the needs
addiction. Unfortunately, despite our greater
understanding of the scope of this public health
of patients in substance abuse treatment is to develop
it is a basic requirement that treatment programs be
approach is heartening and could serve as a model for
problem, our knowledge about how best to treat these
more data to help guide treatment decisions. At
skilled at identifying co-occurring conditions and be
other treatment programs.
individuals remains limited. Our ability to meet the
present, individuals with co-occurring psychiatric
able to facilitate appropriate referrals.
needs of these patients in treatment settings remains
disorders are usually excluded from substance use
uneven. The challenges before the addiction research
disorder research. Conversely, psychiatric disorder
co-occurring psychiatric disorders is an excellent
and treatment community are multifold.
research typically excludes substance-using individuals.
example of the type of approach that is needed to
The first challenge in better meeting the
The Caron Foundation report on addiction and
The end result of this unfortunate convergence of
treatment needs of individuals with substance use
research priorities is that little is known about the best
disorders and co-occurring psychiatric conditions is
practices for the treatment of co-occurring conditions.
The third challenge is prevention. Since
accurate diagnosis. The essential problem facing the
clinician who is treating an individual with a
individuals with psychiatric disorders are at increased
substance use disorder and concurrent psychiatric
risk for substance use problems, an important question
symptoms is, “are the symptoms due to substance use
is “can the early identification and treatment of
or are they independent?” This is almost never an easy
psychiatric disorders prevent the development of
question, with the answer for most patients somewhere
substance abuse?” Other medical conditions, such as
in between. The diagnosis impacts the treatment plan;
diabetes, offer potential models, where early,
2
3
T
raditionally, addiction and mental health issues have been studied and treated independently from each other.
patients with severe psychiatric disorders. However,
female patients are more likely to have a co-occurring
Research programs that study psychiatric disorders generally have not addressed chemical addiction. Chemically
addiction treatment programs that have appropriate
psychiatric disorder than male patients, due to the increased
addicted individuals seek treatment at programs that specifically address addiction, and individuals plagued by
psychiatric resources, such as the Caron Foundation, tend
prevalence of depressive and anxiety disorders found among
to have high rates of patients with mild to moderate co-
women.[5] Female substance abusers tend to have higher
occurring psychiatric and substance-use disorders.
rates of internalizing psychiatric disorders, such as
mental health problems seek treatment at psychiatric facilities.
In recent years there has been much interest in the interconnections between mental health and addiction.
Results from standardized psychological testing of
depression, while male substance abusers tend to have
Although the compulsive use of at least one substance with addictive potential distinguishes chemical addiction from
Caron Foundation adult patients has found that these
higher rates of externalizing disorders, such as conduct
mental health diagnoses, both chemical addiction and psychiatric disorders are caused by a complex interplay of heredity
patients generally have higher levels of psychiatric
disorder.[6] For example, a review of gender differences in
and environmental exposure. The interconnections between mental health and addiction also are easily seen in the high
symptoms and overall distress compared to normative
chemically addicted patients found that anxiety disorders
occurrence of psychiatric disorders in addicted populations and in the high prevalence of addiction in psychiatric
nonpatient populations, although the level of psychiatric
are more common in female heroin-dependent patients,
populations. In addition, psychiatric illnesses may be risk factors for addictions to drugs and alcohol. Co-occurring
functioning of adult Caron Foundation patients is similar to
while antisocial personality disorder is more common
untreated psychiatric illness also is a very poor indicator for recovery from addiction.
individuals in psychiatric outpatient treatment. A survey of
among male patients.[7]
As this report will show, the interconnections between mental health problems and addiction are revolutionizing the
way both diseases are studied and treated. This report highlights the high co-occurrence of addiction and psychiatric
patients admitted to the Caron Foundation relapse
As shown in Figure 2, at admission female Caron
prevention program found that these patients generally
Foundation patients report higher rates of psychological
reported they had experienced psychiatric problems for at
problems, histories of inpatient and outpatient psychiatric
disorders, and describes those psychiatric disorders that have been shown to commonly co-occur with substance abuse
least half the month preceding admission to treatment, and
treatment, rates of current psychiatric treatment, and
and dependence. Finally, this report discusses state-of-the-art treatment options for co-occurring addiction and
over half of the patients reported being considerably or
histories of suicidal ideation and attempts, domestic
psychiatric disorders.
extremely bothered by these psychiatric problems (see
Figure 1).
Figure 2. Psychiatric indicators at admission to
Caron Foundation residential treatment programs, by gender
80
70
Prevalence rates of co-occurring psychiatric and
substance-use disorders are much higher than the
dependent upon illicit drugs than were adults without a
serious psychiatric disorder (2.1%), and were more likely to
prevalence rates for either disorder occurring separately in
abuse or be addicted to alcohol than people without a
the general population. In addition, psychiatric disorders
serious psychiatric disorder (18% compared to 7%).
and addiction increase the risk for the co-occurrence of
either disorder.
Percent of admissions by gender
Section I: Prevalence and Risk Factors
Other research studies confirm the high rates of co-
The 2002 National Survey on Drug Use and Health
53
50
40
38
35
24
32
31
29
30
24
24
20
18
13
13
10
7 6
7
0
Psychological Inpatient Outpatient Current
problem psychiatric psychiatric psychiatric
and the National Comorbidity Survey[2] estimated that the
Suicidal
ideation/
attempt
Homicidal
ideation
Domestic
violence
Self-abuse
Source: Caron Foundation
prevalence rates of co-occurring psychiatric and substanceuse disorders range from almost 14% to 29% in the general
found that approximately 4 million American adults
population. Rates of co-occurring psychiatric and
suffered from both a serious psychiatric disorder and
substance-use disorders are even higher in psychiatric
substance dependence or abuse.[1] Over 20% of adults who
treatment populations. Between 30% to 70% of patients in
abused or were dependent upon drugs or alcohol also had a
inpatient and outpatient psychiatric programs are estimated
serious psychiatric disorder, compared to 7% of adults with
60
occurring psychiatric disorders and addiction. National
surveys such as the Epidemiologic Catchment Area Survey
Prevalence of Co-Occurring Addiction
and Psychiatric Disorders
66
to have co-occurring problems with drugs and
alcohol.[3]
The prevalence of co-occurring psychiatric and
a serious psychiatric disorder who did not abuse substances.
Likewise, the survey found that adults with a serious
substance-use disorders varies among addiction treatment
psychiatric disorder (9.6 %) were more likely to abuse or be
centers because some treatment programs tend to screen out
4
Gender Differences
Prevalence and type of psychiatric co-occurring
disorders tend to differ in male and female substance
abusers. The national Drug and Alcohol Services
Information System found that female patients with a cooccurring psychiatric disorder were more likely to be
admitted to substance abuse treatment than were female
patients without psychiatric problems.[4] A review of
chemically addicted patients in treatment also showed that
violence, and self-abuse than do male patients.
In addition, through standardized psychological testing
using the Symptom Checklist 90-R (SCL-90-R),[8] we
found that the adult female patients at the Caron
Foundation tend to have a greater severity of somatic
symptoms and depressive symptoms than do male patients.
Adult female patients also report a higher number of
psychiatric symptoms and greater intensity of perceived
distress than do adult male patients.
5
Adolescent Issues
The co-occurrence of psychiatric disorders with
substance-use problems tends to be high for adolescents. It
is estimated that between 60% to 75%[9] of adolescents with
substance abuse or dependence have a co-occurring
psychiatric disorder. A national survey of adolescent mental
health issues found that three times as many adolescents
who abused or were dependent on drugs or alcohol had a
co-occurring psychiatric disorder compared to adolescents
who did not abuse substances.[10] Another large-scale survey
of 23 adolescent drug treatment programs across the nation
found that 65% of the sample of young people had at least
one co-occurring psychiatric disorder.[11]
Adolescent patients at the Caron Foundation also are
likely to have co-occurring psychiatric problems. As shown
in Figure 3, a comparison of Caron Foundation adolescent
residential patients (14 to 19 years of age) and adult
patients (20+ years of age) found that, upon admission,
adolescent patients are more likely than adult patients to
report indicators of psychiatric problems. Adolescent
substance abusing youngsters are the disruptive behavior
disorders, attention deficit disorders, and depressive
80
Percent of admissions by age
60
individuals may be drawn to a drug-abusing subculture
adolescent males to have a co-occurring depressive
substance use, although substance abuse may be a risk factor
because this subculture is more accepting of them than
disorder,[13]
and male adolescents are more likely to have an
40
attention deficit
disorder.[14]
Psychological evaluations reveal the most common
psychiatric problems experienced by patients at the Caron
Foundation residential adolescent program are depression
(45%), attention deficit (33%), anxiety (20%), and bipolar
(12%) disorders. A study conducted at the Caron
Foundation that used the Youth’s Inventory-4 [15] for
psychological screening of female adolescent residential
patients found the most prevalent psychiatric symptoms for
the girls were related to depression, conduct, attention
deficit, eating disorders, psychotic thoughts, and anxiety.
Regardless of the specific psychiatric disorder, it does
appear that psychiatric conditions that begin in childhood
dependence.[16] Additionally, adolescents who abuse
substances and who have a co-occurring psychiatric disorder
began using alcohol and drugs at earlier ages than
Risk Factors for Addiction and Relapse
When Psychiatric Disorders Are Present
30
20
The nature of the relationship between some
psychiatric disorders and substance abuse and dependence is
10
0
complicated, and it is often difficult to untangle whether
Psychological Inpatient Outpatient Current
problem psychiatric psychiatric psychiatric
Suicidal
ideation/
attempt
Homicidal
ideation
Domestic
violence
Self-abuse
Source: Caron Foundation
for the development of a conduct
society in general. These individuals may feel less
disorder.[20]
externalizing disorder, such as conduct disorder or an
adolescents without psychiatric problems.[17]
50
important factor for individuals with psychiatric
behavior disorders and anxiety disorders tend to precede
adolescents often have used more illicit substances and
Adolescent
Adult
Other studies of
adolescent substance abusers are more likely than
are more likely to have more severe substance use. These
70
withdrawal. The social context of drug use also may be an
disorders.[23] For example, some chronically mentally ill
make an adolescent more vulnerable to substance abuse and
Figure 3. Psychiatric indicators at
admission to Caron Foundation residential treatment
programs, by age group
appear before substance
dependence.[19]
adolescent substance abusers also have found that disruptive
disorders.[12]
Similar to adult substance abusers, female
especially conduct disorders and anxiety disorders, tend to
substance abuse preceded the psychiatric problems, or vice
versa. Substance use has mood-altering effects, and
stigmatized when they are identified as “drug addicts” than
Psychiatric Risk Factors
Dr. Roger Weiss has identified a number of ways in
which mental distress may become a risk factor for
substance abuse.[21] Individuals with certain psychiatric
disorders may abuse certain drugs because those drugs
relieve their psychiatric symptoms, and research has found
that cocaine-dependent patients with attention deficit
disorder tend to experience an initially calming effect from
cocaine. Individuals affected by depression, anxiety, or
severe rage also have been known to abuse cocaine,
benzodiazepines, and opiates to relieve their psychiatric
symptoms. Substance use that begins as “self-medication”
often becomes substance dependence.
Although many young people experiment with drugs
and alcohol, a subset of people with psychiatric disorders
may not able to stop their abusive behavior.[22] Mental
health problems also may become a barrier to a person’s
ability to understand or change their substance-abusing
behavior. Thus, severely depressed individuals may feel so
hopeless that they do not care if they become addicted, and
the impulsivity and poor judgment associated with mania
may prevent manic individuals from appreciating the
negative consequences of their substance abuse.
Individuals with co-occurring psychiatric disorders and
addiction also may experience more severe withdrawal
symptoms than do addicted individuals who are not affected
by psychiatric disorders. As a result, severe withdrawal
symptoms lead to further abuse of substances to postpone
substance abuse may be mistakenly identified as psychiatric
patients are more likely than adults to report histories of
symptoms.
psychiatric problems, current psychiatric treatment,
histories of suicidal ideation or attempts, homicidal
ideation, and self-abuse.
The most common psychiatric disorders for the
Sequence of Occurrence
There is some evidence to show that many psychiatric
disorders occur prior to substance abuse.[18] The National
Comorbidity Study reported that psychiatric disorders,
6
7
when they are identified as “mentally ill.”[24]
Relapse Issues
Drug- and alcohol-dependent individuals with cooccurring psychiatric disorders tend to have much higher
rates of relapse to addiction than do others without
psychiatric problems, and the severity of psychiatric
problems is one of the most predictive factors for addiction
treatment outcome.[25] In alcohol dependence, the severity
of pretreatment psychiatric functioning more strongly
predicts relapse than the severity of the pretreatment
alcohol dependence.[26] In cocaine dependence, poor
psychiatric functioning has also been found to be among
the top three pretreatment predictors for relapse to
cocaine.[27] In general, psychiatric symptoms, such as anger,
frustration, and stress have been identified as common
triggers for relapse.[28]
The co-occurrence of psychiatric disorders and
addiction also increases the severity of the psychiatric
symptoms for many people. For example, alcoholics with
co-occurring psychiatric symptoms have higher suicide rates
than do other alcoholics.[29] Chronically mentally ill
patients who also abuse drugs and alcohol tend to have
poorer psychiatric treatment outcomes than others. Their
behavior is less appropriate than that of psychiatric patients
who do not abuse drugs or alcohol, and they tend to have
higher rates of rehospitalization and poorer responses to
psychiatric medications.
Section II: Common Co-Occurring Psychiatric Disorders
Rates of mental illness vary according to the
instruments used to assess and measure psychiatric
symptoms. Some instruments like the SCL-90-R[1] are brief
self-reports of psychiatric symptoms. These types of
instruments are useful to screen people for mental distress,
but cannot be used to diagnose a psychiatric disorder.
Instead, psychiatric disorders usually are diagnosed by a
differ from normal periods of sadness in that they tend to be
prolonged and continue during situations that normally
would induce happiness.[4] Depressive disorders also may be
more severe than ordinary sadness. Hopelessness may
develop, and the depressed person may consider ways to
end his or her life. Suicide becomes the most serious
consequence of an untreated depression.
mental health professional, using a wide range of criteria
Individuals in addiction treatment programs tend to
stipulated in handbooks, such as the Diagnostic and
have higher lifetime rates of depressive disorders than rates
Statistical Manual of Mental Disorders.[2] These criteria
found in the general population.[5] Major depression occurs
carefully describe the number, severity, and duration of
certain behavioral symptoms that a person must show in
in approximately 15% to 50% of people who abuse or are
dependent on drugs or alcohol.[6]
The Caron Foundation has found rates of depressive
order to be formally diagnosed with a psychiatric disorder.
The research reports cited in the following section are a
symptoms in its adult patient population ranging from 50%
result of studies that used a variety of tools to assess
of its relapse-prevention patients who experienced a
psychiatric conditions, including self-report measures and
depressed mood in the month prior to treatment, to 65%
diagnostic interviews. Studies that use self-reports of
of its alcoholic patients who experienced an episode of
symptoms generally result in reports of higher psychiatric
depression sometime in their lifetime. As shown in Figure 4,
distress than do studies based on lengthy and
adult female alcoholic patients have a much higher initial
comprehensive psychiatric evaluations.
severity of depression symptoms than do the adult male
alcoholic patients, although by the end of treatment they
Mood Disorders
experience similar rates of depressive symptoms.
A mood is a protracted emotional state that influences
Upon admission, adult female patients at the Caron
a person’s thoughts and behaviors. Mood disorders are
Foundation also report they have had higher rates of
characterized by prolonged or severe emotional experiences
suicidal thoughts and attempts than have male patients
of depression or elation.[3] Although all of us commonly
(see Figure 2).
experience periods of happiness and sadness, we do not
Figure 4. Rates of depressive symptoms at admission
and discharge for adult alcohol-dependent patients
at the Caron Foundation
suffer from a mood disorder unless these emotions become
protracted, supercede all other emotions, and are
20
inappropriate to the situation. For example, happiness at a
Female
Male
celebration is normal and expected, while extreme
15
prolonged elation despite sad circumstances could be a
■
symptom of a mood disorder. As we will see, extreme
depression or elation, or bouncing back and forth between
10
those two extremes, are common co-occurring conditions
with addiction.
5
Depressive Disorders
Everyone occasionally feels “blue.” Depressive disorders
0
Admission
Discharge
Anxiety Disorders
It is estimated that one third of alcoholics will
experience severe depression at least one time during the
Anxiety is an emotion that signals distress or danger. It
period they are in active addiction.[7] Heavy drinking and
is healthy for people to experience moderate levels of
alcoholism may induce depressive symptoms in some
anxiety under appropriate circumstances. However, anxiety
individuals because of alcohol’s depressant properties, and
disorders are due to unregulated experiences of fear and
heavy alcohol use can worsen a person’s co-occurring
panic that are not connected to situations in which we
depression.[8] Depressive states induced or made more severe
would expect to be afraid. Phobias, which are exaggerated
by alcohol usually subside with abstinence.[9] On the other
fears of objects or situations, irrationally induce anxiety in
hand, an underlying depression that began prior to drug or
some people. Anxiety also can be characterized by obsessive
alcohol use will not remit with abstinence, but must be
and uncontrollable thoughts and behaviors, or by intrusive
treated separately from the addiction.[10]
memories of past trauma.[16]
Alcoholics who are also depressed may evidence more
Approximately 10% to 20% of individuals in treatment
severe alcohol use and depressive symptoms than people
for a drug or alcohol addiction have a co-occurring phobia
who are either depressed or alcoholic, but not both. A
or panic disorder upon admission to treatment.[17] It also is
comparison of people who were depressed, alcoholic, or
estimated that over 35% of people diagnosed with a panic
depressed and alcoholic found that the co-occurring disease
disorder will develop a co-occurring substance-use disorder
group had more current and prior psychiatric problems and
at some time during their lifetime.[18] Rates of co-occurring
were likely to report a family history of psychiatric illnesses
panic disorder in addiction-treatment patients range from
than either of the other two groups.[11]
2% to 21%.[19]
Research indicates that an anxiety disorder will precede
Bipolar Disorders
Bipolar disorders are characterized by mood swings that
range from depression to extreme mania. Mania differs from
ordinary happiness by its extreme nature. People tend to be
euphoric or irritated during the manic period, and often are
reckless, easily distracted, disorganized, and impulsive.[12]
Bipolar disorder is one of the most common psychiatric
disorders to co-occur with substance abuse and dependence,
and over 50% of people with substance abuse or
dependence have had at least one bipolar episode during
their lifetime.[13] Similar to substance abusers with other cooccurring psychiatric disorders, substance abusers with
bipolar disorders tend to have more lifetime psychiatric
hospitalizations than those who do not abuse substances.[14]
Cocaine-abusing populations appear to have a higher
prevalence of bipolar disorder than alcohol-abusing
populations.[15] Since the symptoms of bipolar disorder are
very similar to stimulant abuse, it is very difficult to make
an accurate diagnosis for the substance dependence or
psychiatric condition while the person is actively using
stimulants.
Source: Caron Foundation
8
9
addiction in most people, although abuse of stimulants and
withdrawal from alcohol can induce anxiety symptoms.[20]
Alcohol-induced anxiety usually lasts no more than a few
hours in social drinkers who have had only a few drinks.
However, alcoholics may suffer more protracted and severe
anxiety symptoms during withdrawal. Recovering alcoholics
may experience symptoms for up to six months after they
have stopped drinking.[21] Alcohol-dependent individuals
who experienced prolonged withdrawal-induced anxiety or
have a co-occurring anxiety disorder have a poorer
prognosis for recovery from their addiction because abuse of
alcohol decreases symptoms of anxiety.[22]
Symptoms of anxiety are among the most prevalent
psychiatric problems affecting patients at the Caron
Foundation. Over 50% of patients admitted to the Caron
Foundation relapse prevention program for a drug or
alcohol addiction report they experienced anxiety in the
month prior to admission (60.4% male and 53.3% female
patients). These rates of anxiety are even higher for
alcohol-dependent patients. Over three quarters of the
adult alcohol-dependent patients reported anxiety in the
80
70
66
66
64
63
63
Female
Male
58
60
subside following stressful events. However, sometimes the
and conduct disorders, are characterized by steady patterns
introduced to a drug-abusing subculture.[39] The high co-
situation is so uncontrollable and traumatic that individuals
of negative, hostile and defiant behaviors.[33] Youths
occurrence of ADHD and conduct disorders[40] also suggests
continue to experience negative stress reactions long after
diagnosed with disruptive behavioral disorders have serious
that deviant peer culture may be a risk factor for substance
the event has ended. Post-traumatic stress disorder (PTSD)
problems relating to family members, peers, and other
abuse in this population. Deviant behavior encompasses a
is a psychiatric condition in which a person continues to
community members. These children and adolescents tend
number of behaviors that are diverge from socially and
experience negative stress reactions to severe traumatic
to have difficulty controlling their temper and frequently
morally accepted standards, such as truancy, stealing, and
defy adult rules. As their behavioral problems become more
drug use.
50
40
events.[26]
People who suffer from PTSD often reexperience
30
20
10
0
Anxiety
ObsessiveCompulsive
Phobic
Anxiety
the symptoms of the event through intrusive memories.
severe, argumentative behaviors often are replaced by
They may avoid people and places associated with the
physical aggression. Disruptive behavioral disorders are
generally considered to be safe and effective in treating
trauma, and they often are on “high alert” for danger even
among the most common conditions to co-occur with
ADHD,[41] treatment with these high-abuse potential
in ordinary situations.
adolescent substance abuse and dependence.[34]
medications may be risky for substance abusers who have a
Approximately 34% of the adolescent female patients at
greater likelihood of abusing or diverting the medications.
the Caron Foundation report symptoms of oppositional-
Almost half of the adolescent patients (45.5%) at the
defiant disorder and over 60% have reported symptoms of
Caron Foundation who have co-occurring ADHD had been
the more severe conduct disorder.
treated with a psychostimulant medication. As shown in
Surveys of the general population also have found that
Source: Caron Foundation
month prior to admission (76.7% female and 81.8% male
individuals with PTSD have higher rates of substance abuse
patients). As seen in Figure 5, rates of anxious, obsessive-
and dependence than other
compulsive, and social phobic symptoms experienced by
and alcohol disorders affect from 21% to 43% of persons
Co-occurring drug
A recent survey of people in addiction
Caron Foundation adult patients are higher than symptoms
with
found in nonpatient samples based on the normative SCL-
treatment found that almost 90% had experienced a sexual
90-R scores.
or physical attack during their lifetime and over 40% were
Although increased anxiety is related to substance
PTSD.[28]
people.[27]
currently experiencing PTSD related to victimization
crime.[29]
As seen earlier in Figure 2 (on page 5),
abuse in adult populations, the link between anxiety
through a
symptoms and substance abuse among adolescents is less
32% of the female patients and 13% of male patients
clear. Surveys conducted on adolescents in addiction
admitted to a Caron Foundation residential treatment
treatment centers tend to find that anxiety disorders are
program reported they had been victims of domestic
related to addiction.[23] Over 40% of adolescent female
violence. Individuals who develop PTSD following
patients at the Caron Foundation reported symptoms of
exposure to trauma may turn to drugs and alcohol to relieve
generalized anxiety and 29% experienced obsessive
stress or PTSD symptoms.[30]
Individuals with co-occurring PTSD and addiction
thoughts when they were screened for psychiatric problems.
However, community samples suggest that social
often have more severe symptoms of both disorders than do
anxiety may be a protective factor for adolescents. A study
people who suffer from only PTSD or addiction. Individuals
of high school students found that students who were
in treatment for addiction who also have PTSD appear to
socially anxious were less likely than other students to use
have poorer treatment prognosis than patients whose sole
drugs and alcohol.[24] Another national study of adolescents
diagnosis is addiction.[31] Just as other forms of anxiety can
in the community found that anxiety disorders co-occurred
be triggered and worsened by substance-use withdrawal,
at lower rates for substance-abusing adolescents than did
PTSD symptoms can be triggered and made worse following
other psychiatric
disorders.[25]
Post-Traumatic Stress Disorder
Everyone at some time feels “stressed out.” Stress can
be thought of as the psychological and physiological effects
of dealing with situations that challenge or frighten us.
Generally people’s emotional and physical stress reactions
withdrawal, which can lead to a relapse to substance use.[32]
Disruptive Behavior Disorders
Disruptive behavior disorders decrease a person’s ability
to regulate his or her behavior or conduct. These disorders
interfere with normal developmental tasks. Some disruptive
behavioral disorders, such as oppositional-defiant disorder
10
Although Schedule II psychostimulant medications are
Figure 6, the adolescent patients diagnosed with ADHD
Attention Deficit Hyperactivity Disorders
Attention deficit hyperactivity disorder (ADHD)
usually first appears in childhood and is characterized by
inattention. People with this disorder generally are easily
distracted and have difficulty paying attention to tasks or to
others. They also may exhibit impulsive behavior and be
overly active.[35]
Substance-abusing adolescents are more likely to have
ADHD than adolescents who do not abuse drugs or
alcohol. Estimates of comorbidity of substance-use disorders
and ADHD in addiction treatment settings range up to
50%.[36] Approximately 34% of adolescent patients at the
Caron Foundation have been diagnosed with ADHD at
some point during their lifetime, and 19% of the
adolescents are currently diagnosed with ADHD at the time
of admission.[37] Adults with ADHD also have higher rates
of substance abuse than other adults. One study found that
52% of adults diagnosed with ADHD also met criteria for a
substance-use disorder compared to 27% of adults with no
ADHD.[38]
ADHD-related difficulties in regulating behavior often
impair children’s ability to form social relationships. Recent
research suggests that children with ADHD are more likely
to form friendships with deviant peers than with other
children, and as a result, may be more likely to be
11
were more likely than other adolescent patients to report a
history of psychostimulant abuse. Also, 20% of the
adolescent patients with co-occurring ADHD reported
histories of illicit diversion of their medication, either by
sale, barter, or gift to others.[42]
Figure 6. Lifetime history of pychostimulant abuse by
Caron Foundation adolescent patients
50
42
40
30
Percent
Non-patient normative SCL-90-R scores
Figure 5. Rates of anxiety-related symptoms of
adult residential patients at the Caron Foundation
25
20
10
0
ADHD Lifetime
Diagnosis
No ADHD Diagnosis
Source: Caron Foundation
Eating Disorders
Eating disorders affect a person’s body image and
attitude toward food consumption. These disorders are
characterized by abnormally low weight caused by food
restriction (anorexia nervosa), by unhealthy methods of
common among patients with schizophrenia and other
dependent individuals tend to have higher rates of
food purging (bulimia nervosa), such as self-induced
psychotic disorders and the most commonly abused
personality disorders compared with alcoholics.[58]
vomiting or laxative abuse, or by reoccurring episodes of
substances are alcohol, marijuana, and cocaine.[54]
According to a survey[59] of patients in treatment for
unhealthy food binges.[43] Adolescent boys and men
Additionally, schizophrenia and substance dependence both
alcohol or drug dependence, 78% of the alcoholic patients
sometimes are afflicted with these disorders, especially if
tend to develop in adolescence and young adulthood.
had at least one personality disorder, and 91% of the drug-
they engage in activities like wrestling in which weight is
important.[44]
It is difficult to determine a specific causal relationship
dependent patients had at least one personality disorder.
between schizophrenia and substance dependence. The self-
The average number of personality disorders diagnosed for
found among adolescent girls and women, and much of the
medication model proposes that patients abuse drugs or
each patient averaged almost two per alcoholic patient and
research on eating disorders has been conducted with
alcohol in an attempt to decrease distressing symptoms.
four per drug-dependent patient.
female samples.
However, prolonged and severe abuse of certain drugs, such
The co-occurrence of any personality disorder in
as hallucinogens and amphetamines, may induce psychotic
addition to antisocial personality disorder in an individual
However, eating disorders are more commonly
Although relatively low rates of eating disorders are
disorders in some
estimated to occur in the general population, these
people.[55]
with any drug addiction is associated with greater
Diagnosis of psychotic disorders becomes more difficult
psychiatric distress, more life problems, and poorer
disorders are much more common in populations with co-
abused by bulimic women include cocaine, amphetamines,
occurring substance abuse or dependence People who suffer
and other stimulants that suppress appetite or increase
when the individual also is abusing drugs because use of
interpersonal skills compared with addicts who do not have
from an eating disorder are up to five times more likely to
metabolism, and heroin to induce vomiting.[50] A survey of
some drugs causes psychotic symptoms, such as
antisocial tendencies.[60]
abuse drugs or alcohol than people without an eating
adolescent and adult female patients at the Caron
hallucinations. Psychoses induced by stimulant use and
disorder, and people who abuse drugs or alcohol are up to
Foundation[51] found that almost 15% of the patients had
hallucinogens closely resemble the symptoms of paranoid
to any one of the types of personality disorders because all
11 times more likely to have an eating disorder than those
symptoms of eating disorders, and that patients who
schizophrenia, and psychotic drug users are likely to receive
of these disorders have been found in individuals with drug
A review of over 50
reported cocaine dependence had more severe symptoms of
found much stronger associations with substance
eating disorders than did patients whose drug of choice was
who do not abuse drugs or
studies[46]
alcohol.[45]
an incorrect diagnosis of
It is not possible to link substance abuse or dependence
or alcohol dependence. However, most research finds that
schizophrenia.[56]
Treatment for addiction and mental illness is more
antisocial personality disorder and borderline personality
abuse for eating disorders that involve unhealthy methods
alcohol, opioids, or marijuana. As seen in Figure 7, Caron
difficult when these problems co-occur. Many addiction
disorder, which are described in the following sections, are
of purging food than for eating disorders characterized by
Foundation female patients who reported symptoms of
treatment programs are not designed to meet the special
among the most prevalent personality disorders found in
severe food restriction. However, other reviews of the
eating disorders were likely to be dependent on alcohol,
needs of people with severe mental illness and do not
chemically addicted populations.[61]
research also indicate that the more severely girls and
cocaine, opiates, or marijuana.
accept individuals with active psychoses into the program.
women restrict food intake, the more likely it is that they
will abuse alcohol and
drugs.[47]
Psychiatric settings, on the other hand, often do not have
Psychotic Disorders
Eating disorders and substance abuse share a number of
Psychotic disorders are among the most severe forms of
staff trained in treating chemical addiction. In addition,
substance abuse and dependence in severely mentally ill
characteristics. Shared risk factors identified by the
mental illness. They are characterized by marked changes in
patients is associated with treatment noncompliance,
National Center on Addiction and Substance Abuse at
personality and a severe decrease in social functioning.
increased symptom severity, and relapse.[57]
Columbia University[48] include common brain chemistry,
Individuals with these illnesses often lose touch with reality
family history, emergence during times of stress or
and are guided by bizarre delusions. They may be unable to
transition, association with low self-esteem, depression,
focus on one topic, and, instead, shift from one unrelated
anxiety, history of physical or sexual abuse, and media and
thought to another subject without appearing to understand
relating to others that people develop over time. Some
societal influences.
that the topics are not connected. Psychotic disorders also
people are shy, while others are bold. Some tend to act
are marked by profound disturbances in perception, and
impulsively, while others are more thoughtful. These
and dependence and eating disorders, especially for eating
afflicted individuals may hear, see, or feel things that do not
personality types are not problematic unless they cause
disorders that rely on methods of purging food. Women
exist.[52]
significant problems or distress. Personality disorders develop
There is a strong association between alcohol abuse
who suffer from co-occurring bulimia nervosa and alcohol
Individuals with severe mental illnesses have high rates
dependence tend to have higher rates of suicide attempts,
of substance abuse. Prevalence rates as high as 50% have
anxiety disorders, and other substance dependence than do
been found for co-occurring schizophrenia and substance
women with bulimia nervosa
alone.[49]
Other drugs often
abuse or dependence.[53] Substance abuse tends to be
12
Personality Disorders
Personality comprises the enduring ways of thinking and
when personality traits become rigid and prevent the person
from adapting to social and environmental changes.
Prevalence rates of personality disorders in substance
abuse populations range from 25% to 75%, and drug
13
Antisocial Personality Disorder
Antisocial personality disorder (ASPD) begins in
childhood or adolescence and is characterized by a
pervasive pattern of irresponsible and hostile behaviors.[62]
Antisocial behaviors break social norms and include
destructive or illegal activities that show a lack of remorse
for the consequences. People with ASPD tend to be
aggressive, reckless, and suspicious of others. Often these
individuals also complain of tension and are unable to
tolerate boredom. They seem unable to sustain lasting
relationships with others. Antisocial behaviors occur three
times more frequently in males than in females.
There is a strong link between alcoholism and drug
addiction and antisocial personality disorder. Alcoholics
with ASPD tend to have histories of early initiation to
alcohol, other substance abuse, and poor treatment
prognosis.[63] Individuals with co-occurring ASPD and
substance dependence also have higher rates of arrests and
individuals with substance abuse or dependence, and occurs
criminal activity, lower levels of education, less stable
in 10% to 30% of this population.[66]
The co-occurrence of BPD and substance abuse or
employment histories, and more family and social problems
compared with alcohol or drug dependent individuals
dependence tends to present more mental health symptoms
without ASPD.[64] Antisocial heroin abusers also have
than either disorder alone. A comparison of patients in
higher rates of drug injection and needle sharing than do
treatment for co-occurring BPD and substance abuse with
other heroin abusers.
BPD patients without substance abuse found that the
patients with both disorders were younger at their first
hospitalization, and had greater levels of borderline
system and has resulted in segmented and disconnected
Psychiatry and addiction treatment have shared an
uneasy historical relationship leading to service delivery
care. However, as we learn more about the interconnections
disconnections and difficulties in integrating psychiatric
between mental health and addiction, an increasing
and addiction treatments.
number of treatment programs are acknowledging the
necessity of addressing mental disorders and addiction. In
Service Delivery Disconnections
1999 the Substance Abuse and Mental Health Services
Initially, drug and alcohol addictions were diagnosed by
symptoms seven years following their hospitalization.[67]
psychiatrists as “sociopathic personality disorder.”[1] At that
Patients with co-occurring BPD also were more than twice
time medical professionals did not recognize that addiction
as likely to be rediagnosed with borderline personality
was a primary disease that differed from other psychiatric
disorder at the seven year follow-up than were BPD patients
conditions and required specialized treatment. Instead, the
who were not substance abusers. Similar to other research,
psychiatric community unsuccessfully attempted to treat
this study also found the patients with co-occurring
addiction through the prevalent method of psychoanalysis.
substance abuse and borderline personality disorder were
Repeated failure of this method of treatment convinced
more likely to become suicidal than patients who were not
many mental health professionals that addicts and
substance abusers.
alcoholics were not treatable and disenfranchised them
Administration surveyed over 15,000 public and private
addiction and psychiatric treatment programs and found
that programs that treated psychiatric disorders either in
combination with substance abuse or alone were more
likely to address substance abuse issues than programs that
focused primarily on substance abuse (see Figure 8).[5]
Figure 8. Percent of treatment facilities providing
dual diagnosis programs, by primary focus 1999
70
from the mental health system.[2]
60
Early proponents of the disease model of addiction[3]
Percent of Facilities
Borderline Personality Disorder
Borderline personality disorder (BPD) is characterized
by an all-encompassing pattern of instability of mood,
interpersonal relationships, and self image.[65] A person with
BPD often lacks a sense of identity and is unable to decide
upon important life issues, such as career, types of friends, or
sexual orientation. The individual also is unable to
maintain steady moods, which often shift among extremes
of depression, anger, and anxiety. BPD is more commonly
diagnosed in females than in males.
Borderline personality disorder is among the most
prevalent of the personality disorders diagnosed in
Section III: Addiction and Mental Health Treatment
broke new ground in their assertion that alcoholics and
addicts were not mentally ill but suffered from a primary
chronic disease that had psychological, as well as spiritual,
physiological, and social impairments. These advances led
67%
57%
50
40
38%
30
20
10
to the development of specific diagnostic categories for
alcohol and drug dependence, and to the development of
0
Mix of Substance
Abuse and Mental
Health Services
specialized treatment for addiction. These developments
greatly benefited individuals with drug and alcohol
Mental Health
Services
Substance
Abuse Services
Source: 1999 SAMHSA Uniform Facility Data Sheet
addiction because they paved the way for specialized
research into the etiology and treatment of these diseases.
The separation of addiction from mental health has
Diagnostic Issues
also had the unintended result of decreasing the ability of
A primary stumbling block for individuals with co-
people with co-occurring mental health and addiction
occurring addiction and psychiatric disorders is correctly
issues to receive integrated treatment.[4] Today, most states
diagnosing both conditions.
and localities operate separate programs to license and
oversee addiction and mental health treatment. Many
Clinician Expertise
All too often, people with both problems are
underdiagnosed because treatment providers do not have
sufficient training in both addiction and mental health
treatment. Over half the patients with a co-occurring
disorder who were treated in New Jersey’s substance abuse
health care insurance programs also have established
separate criteria and reimbursement policies for addiction
and mental health services.
The separation of mental health and addiction into
distinct treatment service delivery systems also has
decreased communication between professionals in either
14
15
and mental health treatment programs were not identified
Figure 9. Comparison of initiation to drugs and alcohol and
ADD diagnosis for Caron adolescent patients
as having a co-occurring disorder by the substance abuse or
mental health treatment
system.[6]
Professionals in the field
of mental health often miss a second diagnosis of substance
abuse, and addiction treatment professionals tend to miss
psychiatric diagnoses.
ADD Diagnosis
professionals to treat individuals with co-occurring
0
conditions. A study of over 1,000 patients who reported
2
4
6
8
10
12
14
16
Years of Age
symptoms of depression to their primary care providers
Source: Caron Foundation
found that less than 14% of patients with co-occurring
occurring drug abuse received counseling for substance
abuse.[7]
The Caron Foundation provides education and
training in the treatment of drug and alcohol addiction to
over 50 primary care, psychiatry, and other health care
professionals and students a year. An evaluation of Caron’s
training program found that the medical trainees reported
significantly increased skills in substance abuse and
dependence diagnosis following their
initially induced by cocaine abuse, which continue after
recovery.[11] Some psychiatric conditions may be risk factors
evaluation of physical functioning, various biochemical
person addicted to cocaine who minimizes or denies the
tests, such as urine toxicology and breathalyzer, and
addiction may not benefit from psychiatric treatment for
members.[14]
anxiety if he or she continues to abuse cocaine. Also,
An important element of diagnosis is selecting the
treatment adherence is impacted by psychiatric symptoms
appropriate time for the diagnostic interview. If a patient is
that impair judgment and decrease the ability to relate to
diagnosed during an active addiction or during early
others. Thus, a depressed alcoholic who is unable to form a
withdrawal, the diagnostician may mistake substance abuse
therapeutic relationship with the psychiatric care provider
and withdrawal symptoms for psychiatric conditions,
may relapse to alcohol abuse.
leading to unnecessary or, perhaps, harmful treatment. On
As we have seen, some individuals with co-occurring
the other hand, if the specialist waits too long before
disorders are drawn to substance-abusing groups. Individuals
making a diagnosis, the psychiatric symptoms may increase
with co-occurring disorders who do not have supportive and
and the patient may
relapse.[15]
educated support networks may feel pressured to abuse drugs
for substance abuse and dependence. For example, a person
with a preexisting psychiatric condition, such as depression,
may “self-medicate” with illicit stimulants in order to
decrease the depression. Likewise, a person with an eating
disorder may abuse substances such as heroin or cocaine in
order to suppress appetite.
training.[8]
Differential Diagnosis
One of the most vexing aspects of diagnosis concerns
how to distinguish a separate psychiatric condition from
psychiatric symptoms that occur as the result of substance
abuse.[9] Sometimes the symptoms of substance abuse and
withdrawal mimic those of psychiatric disorders, and
substance abuse and withdrawal may be confused with a
psychiatric disorder. For example, a retrospective survey of
adolescents admitted to the Caron Foundation for addiction
treatment found that the adolescents tended to begin to
experiment with drugs and alcohol during the same time
period they were diagnosed with ADHD(see Figure 9).[10] It
is possible that the attention problems experienced by some
of these youngsters were due to illicit drug use, not a
psychiatric condition.
Symptoms of psychiatric disorders induced by substance
abuse and withdrawal generally cease over a period of
abstinence and do not require long-term psychiatric care.
However, some substances may induce psychiatric disorders
that do not remit with recovery, such as panic attacks
risk for premature termination of treatment. For example, a
information from family
Initiation to Drugs
and Alcohol
Primary care physicians often are the first health care
alcohol abuse and less than 7% of patients with co-
Comprehensive diagnostic assessment also includes an
Diagnosis of Co-Occurring Disorders
Drs. Kosten and Kleber, leaders in the field of addiction
psychiatry, note that differential diagnosis of psychiatric cooccurring conditions is essential in order to provide
effective treatments for the psychiatric disorders.[12]
Differential diagnosis requires accurate information about
the types of drugs abused, the stage of abuse from
intoxification through withdrawal, as well as the patient’s
history of psychiatric illness and substance abuse.
In order to understand the relationship between
substance abuse and psychiatric symptoms, clinicians should
conduct a thorough substance use and mental health
history of the patient.[13] This history includes development
of a timeline of when the psychiatric symptoms first
appeared, when they worsened, and their relationships to
when the person initiated substance use, when substance
use exacerbated to abuse or dependence, and when periods
of abstinence and relapse occurred. The diagnostic
interview also should include the patient’s report of his or
her subjective assessment of the effects substance abuse has
had on mental health functioning, as well as the effects of
psychiatric symptoms on drug or alcohol use.
16
or alcohol or to cease psychiatric medication.[17] It may be
Treatment Issues
difficult for a person with a chronic mental illness to break
away from a subculture that identifies with drug abuse.
Early unplanned discontinuation of treatment and a
lack of compliance with treatment plans are among the
Also, although the official policy of Alcoholics Anonymous
most prevalent problems for individuals with co-occurring
is to avoid interference with the legitimate prescription of
disorders. Adherence to treatment for this population is
medications, some “old-timers” in recovery may mistakenly
complicated by the demands of two separate systems–
advise newcomers to abstain from all drugs, including
treatment for mental health issues and treatment for
psychiatric medication due to misunderstandings about the
addiction. The use of pharmacotherapy is an important
differences between legitimately prescribed medications and
treatment issue to consider in order to break the cycle of
substance abuse.
The addiction treatment field has developed a number
relapse to addiction and psychiatric disorders.
of strategies to improve treatment adherence that focus on
Treatment Adherence
Individuals with co-occurring addiction and psychiatric
disorders often have to deal with these two separate
systems, and when they experience difficulties with either
system lose their ability or motivation to adhere to other
one. Treatment adherence requires the patient to transition
from one level of care to another, attend psychotherapy and
addiction treatment sessions, practice a 12-step program,
comply with medication rules, abstain from alcohol and
drugs of abuse, change lifestyle, accept family involvement
and social supports in treatment, and complete treatment
assignments.[16]
Important factors in treatment adherence involve the
individual, the individual’s social network, and the
treatment system. Patients with low levels of motivation for
recovery or who are in denial of their substance abuse are at
17
the early phase of recovery.[18] Like many treatment
programs, the Caron Foundation has found that most of its
patients who relapse tend to abuse substances within the
first six months following treatment. Treatment programs
that address how to identify and manage cravings and how
to recover from a return to substance use may increase
treatment adherence.[19] Also, treatment programs that
provide continuing care counseling to assist in the
transition from one level of care to another level also may
increase the likelihood that the patient will continue in
treatment.[20]
Breaking the Cycle of Addiction
and Psychiatric Illness
Treatment issues are intertwined for patients with cooccurring psychiatric and addiction disorders. These
patients require education concerning the interconnections
because they addressed symptoms caused by the misuse of
Otherwise, the symptoms of some psychiatric conditions,
with PTSD symptoms and over 60% of the patients
of their conditions, and education on how to break the
addictive substances. Other medications with high abuse
like PTSD and eating disorders, may increase and
reported the sessions helped them with substance abuse
negative cycle of psychiatric symptoms and substance abuse
potential may not be appropriate for substance-abusing
precipitate relapse to substance use.
symptoms. Almost 95% of the patients reported they will
(see Figure 10).
patients.
Exacerbation of
psychiatric
symptoms
Abuse of Drugs
& Alcohol
groups as part of their recovery program. Also, it was not
address symptoms of psychiatric disorders. However, most of
multidisciplinary treatment strategies. Since the patient’s
difficult to train clinical addiction staff in the approach
these medications have not been tested on populations of
treatment providers are part of the same treatment program,
because the manual is clearly written. Development of such
individuals who abuse or are dependent on drugs or alcohol.
they are able to share information freely and work together
manuals for the treatment of other psychiatric disorders will
It is important to seek treatment from psychiatric
on formulating treatment plans. Staff are able to consult
increase integrated treatment of psychiatric disorders in
professionals who are experienced in the treatment of co-
with each other on appropriate pharmacological and
addiction treatment centers.
occurring disorders. It also is important to follow medical
psychotherapeutic interventions, nutritional needs, and
advice and to abstain from illicit drug or alcohol use,
relapse triggers.
because these drugs can have adverse effects when taken
with drugs and alcohol, and other certain medications.
Increased
Stress
Integrating Psychiatric and
Addiction Treatment Approaches
An exacerbation of psychiatric symptoms may
The following discussion describes three different
Integrated treatment is cost-effective in the long
term,[26] because it breaks the cycle of addiction and mental
illness. However, the requirements to support staffs of
In addition to increased communication and joint
treatment planning between addiction and mental health
psychiatric and addiction clinicians increase initial expense
treatment staffs, integrated treatment programs are being
and decrease its feasibility for many publicly or privately
developed to address specific psychiatric disorders that
funded programs.
occur within an addicted population. For example, Seeking
Safety[25] is a how-to manual describing an effective
precipitate relapse to addiction, and relapse prevention
approaches to the treatment of co-occurring substance abuse
treatment for PTSD and addiction. Using cognitive-
education can teach patients how to identify and handle
and psychiatric disorders. Patients may receive integrated
behavioral techniques, it focuses on the cognitive,
their specific psychiatric-relapse triggers. Similarly,
treatment for both disorders in one treatment program, or
behavioral, interpersonal, and social-support needs of
substance use may exacerbate psychiatric symptoms and
they may receive concurrent treatment from separate
persons with PTSD and substance abuse or dependence. As
may decrease the efficacy or increase negative side effects of
treatment programs that coordinate patient care. Finally, at
shown in Figure 11, female adult patients at the Caron
psychiatric medications.
times, sequential treatment (treating one disorder then the
Foundation’s extended care program who participated in
other) of addiction and psychiatric illness may be the best
Seeking Safety treatment groups reported the sessions were
approach, depending on the severity of either condition.
helpful to them.
Individuals with co-occurring psychiatric and addiction
disorders also may need help in learning how to
differentiate between normal emotional states and
psychiatric symptoms, and how to cope with negative
emotional states without relying on drugs for selfmedication.[21]
Pharmacological Treatment
David O’Connell, Ph.D., psychological consultant to
the Caron Foundation, has found that it is not unusual for
patients with co-occurring disorders to enter addiction
treatment with up to six different psychiatric
medications.[22] Medical staff trained in psychiatry and
addiction should review all prescriptions to determine
which ones are most effective for the individual’s chronic
mental health conditions, which ones address acute
detoxification symptoms, and which ones to discontinue.
Some medications may not be necessary after abstinence
use the information they learned in the Seeking Safety
benefit of an integrated treatment program and facilitates
A wide variety of medications have been developed to
Figure 10. Negative cycle of
psychiatric symptoms and substance abuse
Communication among treatment providers is a major
Over 54% of the patients who participated in the
Integrated Treatment
Integrated addiction and mental health treatment may
occur within formal dual-diagnosis facilities, or in addiction
treatment programs or psychiatric facilities that employ
clinical specialists for both conditions. These programs
should include psychopharmacologic, psychotherapeutic,
and addiction treatments, including detoxification, relapse
prevention, and 12-step education.[23]
Integrated care is the treatment modality of choice for
a number of co-occurring psychiatric disorders, such as posttraumatic stress disorder (PTSD).[24] Integrated treatment
approaches focus on both the addiction and mental health
problems at the same time. Patients may experience
reductions in the severity of both problems and, thereby,
break the negative cycle of co-occurring disorders.
18
Seeking Safety sessions reported the sessions helped them
19
Concurrent Treatment
Another approach to treatment for addiction and
psychiatric disorders is to treat both problems concurrently
in separate treatment systems. In the same way that patients
with co-occurring depression and asthma are treated by
separate specialists, individuals suffering from addiction and
depression also may receive concurrent, but separate,
addiction and mental health treatment. This method may
work well for patients who are unable to attend a program
that treats both addiction and mental health, and who are
able to contend with both treatment systems.
Concurrent but separate treatment entails a high
degree of coordination and communication between
multiple treatment programs. The mental health provider
needs a complete substance abuse history in order to
determine the impact of substance abuse on the patient’s
mental functioning, and the addiction treatment provider
also must be aware of the influence of psychiatric symptoms
on substance use. Ideally, both treatment providers would
work together to formulate a treatment plan that addresses
both types of disorders, and keep each other appraised of
relapses to substance use and exacerbation of psychiatric
symptoms.
Since the mental health and addiction treatment
systems have strict guidelines concerning patient
confidentiality, patients must take the initiative to consent
multiple providers with the ability to communicate with
each other. If this essential communication does not occur,
the patient will receive parallel, but disconnected
treatment, which may result in poor care.
Sequential Treatment
Integrated or concurrent treatment approaches may not
be necessary or even advisable for all patients. Patients with
severe mental illness, such as an active psychosis, may
require separate psychiatric care prior to addiction
treatment. Also, patients at severe risk for self-harm or
harm to others may need to be stabilized in a psychiatric
setting before they can be safe in a more loosely structured
addiction treatment program. Similarly, addicted patients
whose psychiatric symptoms are mild or controlled may
benefit from a complete focus on addiction treatment.
Treatment always should be individualized to the
problems and severity of problems for each patient, and
sequential treatment may meet the individualized needs of
certain patients. For example, following an initial inpatient
detoxification from drug abuse, a psychotic patient may
need to be stabilized in a psychiatric program first in order
to become ready for an episode of addiction treatment. A
more severely addicted and highly anxious patient may
require inpatient detoxification and an emphasis on
addiction treatment first to establish the abstinence
necessary for a complete psychiatric evaluation. On the
other hand, a motivated and resourceful substance-abusing
and depressed individual may benefit from concurrent
outpatient treatment.
It also is important to remember that recovery is
nonlinear and that relapses are symptomatic of both
addiction and psychiatric illness.[27] Although addiction and
psychiatric illness may create a negative cycle in which
each disorder increases the likelihood of relapse to the
other condition, at various times in life, individuals with
co-occurring disorders may have one condition exacerbated
over the other. Sequential treatment provides the focus on
the aggravated condition that requires immediate attention
in order to keep the other disease in remission.[28]
Continuing Integrated Care
Sequential treatment for addiction and psychiatric
disorders may benefit people with co-occurring disorders if
the discrete treatment episodes are integrated into an
overarching treatment plan that is monitored by
professionals trained in mental health and addiction.
Likewise, individuals discharged from concurrent psychiatric
and addiction treatment or integrated treatment programs
also require long-term, continuing-care plans for recovery.
Case management programs in which one professional
in a network of different clinical programs coordinates care
and communicates with all treatment providers are very
effective in maintaining recovery.[29] The Caron
Foundation’s Recovery Care Management program and
other intensive case management programs provide an
ombudsman to negotiate the confusing array of services
needed by individuals with co-occurring disorders. Without
these types of treatment management programs, patients
may easily fall between the very wide cracks of the mental
health and addiction treatment service delivery systems,
and may receive disconnected and contradictory episodes of
treatment.
Participation in self-help groups, such as 12-step
programs, also may be helpful for recovery, although
individuals with co-occurring addiction and psychiatric
disorders face obstacles not encountered by other people in
recovery who do not have mental health problems. Some
psychiatric disorders, such as social phobias and acute
psychosis, make it difficult for individuals to function in
social groups. Active participation in 12-step activities has
been found to be more effective than mere attendance at
meetings.[30] If social phobias prevent individuals from
attending meetings, they can benefit from the 12-step
program by engaging in other activities, such as contact
with their sponsor and work on the twelve steps. Also,
special 12-step groups like Dual Recovery and Double
Trouble are designed for individuals with severe mental
disorders to allow them to participate in a community
where both of their addiction problems and psychiatric
disorders are accepted.[31]
Recommendations for Treatment
4. Select an integrated treatment program that is able
As we have seen, there are high rates of co-occurrence
5. If integrated treatment is not available, make certain
between addiction and psychiatric disorders. Often the
disconnected addiction treatment and mental health
that your separate psychiatric and addiction
treatment systems do not correctly diagnose these co-
treatment providers are aware of each other’s
occurring conditions. Even if appropriate diagnosis of both
treatment goals and communicate with each other.
disorders is made, there are many obstacles to receiving
6. Otherwise, select a treatment program that focuses
beneficial treatment that addresses both mental health and
on your most pressing problem and be ready to
addiction issues.
engage in treatment for the other problem when your
Individuals afflicted by mental health and addiction
condition stabilizes.
problems may not be able to deal with the complexities
7. Make a personal commitment to recovery and adhere
created by separate treatment systems. Their ambivalence
to your treatment goals.
concerning addiction treatment and recovery and
8. Accept the assistance of others, such as professional
psychological impairments often impedes their ability to
case managers, to facilitate your continuing care with
obtain appropriate types of treatment. Social supports, like
all your treatment providers.
friends or family members, who are uneducated in the
9. Continue your formal addiction treatment program
treatment needs for addiction or mental health also may
unintentionally discourage abstinence or compliance with
with a commitment to long-term recovery by
psychiatric treatment. Finally, the broader issues of separate
engaging in a 12-step program.
10. Identify your specific warning signs for exacerbation
treatment systems and providers, such as difficulty of
coordination and greater expense, also produce significant
of psychiatric symptoms and cravings for substances,
barriers to care.
and reengage in formal treatment when necessary!
However, it is possible for individuals with co-occurring
Final Thoughts
substance abuse and psychiatric disorders to receive
As we have seen, a significant number of individuals
appropriate diagnosis and care and to break the negative
cycle of addiction and mental illness. These
have co-occurring mental health and addiction problems.
recommendations are designed to break down the barriers
These numbers most likely will increase as clinicians
and increase the likelihood of recovery for people with co-
become better able to diagnosis psychiatric and substance
occurring disorders:
abuse disorders. Better diagnosis, however, does not always
lead to better treatment. This report has highlighted the
1. Abstain from drug or alcohol use if you experience
any troubling psychological symptoms prior to,
pitfalls that individuals experience when receiving separate
during, or following substance use.
mental health and addiction treatment where neither is
closely coordinated. The Caron Foundation has learned
2. Abstain from drug or alcohol use if you find you are
using substances more frequently to deal with
that long-term recovery is enhanced by treatment that
emotional problems.
focuses on the needs of the entire individual rather than a
specific segment of the person. Although our specific
3. Seek an evaluation from a clinician experienced in
addition and psychiatric disorders if you are unable to
treatment program is not the only path for recovery, we
hope that our philosophy, which respects the complexity of
maintain a significant period of abstinence or if your
recovery, is shared by all.
psychiatric symptoms do not decrease with
abstinence.
20
to address your addiction and psychiatric needs.
21
Section IV: Addiction and Mental Health
Treatment at the Caron Foundation
evaluation gives the primary counseling staff necessary
follow-up appointments are often scheduled to monitor
treatment guidance for working with patients with
the patient’s condition and review the effectiveness or
psychological complications or co-occurring disorders.
appropriateness of medications prescribed.
Frank Murphy, Ph.D.
Director of Psychological Services
Caron Foundation
The evaluation is comprehensive and addresses issues
T
Once a patient is admitted
he Caron Foundation provides psychological
In addition to providing consultation to the
that can be treated immediately, those that require long-
counseling staff, psychologists at Caron are also available
term care, and also those that require treatments not
to conduct individual therapy to patients when indicated.
available at the Caron Foundation.
Psychologists offer Caron patients group therapy and
Case consultation is regularly available to counselors
group lectures, which focus on areas such as coping skills,
and psychiatric diagnostic and treatment
for treatment at the Caron
at the Caron Foundation. Clinical psychologists in the
recovery issues for special populations, and relationships
services within a primary chemical
Foundation, he or she receives
adult residential treatment programs attend each of the
in recovery. Caron’s psychology team also offers a broad
dependency treatment setting. Given the high prevalence
a complete psychological
weekly treatment-plan update meetings to provide
range of training and lectures to all treatment staff on
of co-occurring psychiatric disorders with substance
evaluation, which is a key
consultation to counselors on the management of adult
topics related to mental health and addiction.
abuse, many Caron patients have been diagnosed with
component in planning
patients with co-occurring psychiatric disorders or
psychiatric disorders in addition to substance abuse.
comprehensive treatment. A
psychological symptoms that could impact treatment.
comprehensive and integrated treatment approach is
clinical psychologist conducts a
Clinical psychologists in the adolescent program also
most effective in dealing with chemical addiction.
begins at the intake process. Individuals with a history of
psychological evaluation of all adolescent patients
offer weekly consultation to counselors regarding these
Providing psychotherapeutic and pharmacological
psychiatric problems are reviewed for their suitability for
admitted to the adolescent treatment program as part of
same issues in adolescents. The clinical psychologists also
services is an integral part of Caron’s approach and plays
primary addiction treatment at Caron. Symptoms that are
the total biopsychosocial assessment. All adult patients
make referrals to the consulting psychiatrists when
an important role throughout the continuum of patient
reviewed by the Caron Admissions Screening Team
admitted to the adult residential treatment programs
medication initiation or management is warranted in
treatment at Caron, from initial assessment, to diagnosis,
(CAST) include current or prior suicidal behavior,
complete the Symptom Checklist 90-R (SCL-90-R),1 a
both adult and adolescent patients. The psychiatrist
to treatment for Caron patients, and to the training of
violence or aggression, psychiatric diagnoses, current or
brief but comprehensive psychological self-report
conducts a full evaluation after the patient is referred and
and Caron’s own counseling staff.
prior psychotic symptoms, mood swings, eating disorders,
inventory that assesses a number of dimensions of
and use of psychiatric medications. CAST consists of
psychological dysfunction and serves as an initial
directors from the adult and adolescent treatment
screening test. A staff clinical psychologist then follows
programs, medical staff, and clinical psychologists from
up with a psychological evaluation interview with each
adult and adolescent services.
patient.
The assessment of patients’ psychiatric functioning
The Caron Foundation believes that a
The psychological evaluation for all patients includes
The primary criteria for admission of patients with a
co-occurring psychiatric disorder is that the patient be
pertinent historical data such as substance abuse history, a
stabilized and that he or she has the cognitive and
mental status exam, a diagnostic profile, and treatment
emotional ability to benefit from the counseling and
plan recommendations. The psychological evaluation
education required for the treatment of addiction.
serves a number of functions including the assessment of
Patients who require psychiatric medications, but are
co-occurring psychiatric conditions that may be present
stable on them, are appropriate for treatment if they meet
and that may require additional treatment such as
the other admission criteria.
psychotherapeutic or pharmacological intervention. The
22
23
Notes
44. National Center on Addiction and Substance Abuse at
9. Weiss and Mirin 1989
Columbia University 2003
10. Gordon, Tulak, and Troncale, in press
45. National Center on Addiction and Substance Abuse at
11. Rosenthal and Westreich, 1999
Columbia University 2003
Section I: Prevalence and Risk Factors
5. Regier et al. 1990
1. Substance Abuse and Mental Health Services
6. Cacciola et al. 2001
Administration 2003
7. McLellan et al. 1983
2. Kessler et al. 1994; Kessler et al. 1996; and Regier et al. 1990
8. Atkinson and Misra 2002
3. Rosenthal and Westreich 1999
9. Atkinson and Misra 2002; Anthenelli and Schuckit 1993
4. Drug and Alcohol Information System 2003
10. Atkinson and Misra 2002
5. Cacciola et al. 2001
11. Leibenluft et al. 1993
6. Latimer et al. 2002
12. American Psychiatric Association 1998
7. Kreek 2000
13. Regier et al. 1990
8. Derogatis 1994
14. Brady and Sonne 1995
9. Armstrong and Costello 2002; Grella et al. 2001
15. Brady and Sonne 1995
10. Kandel et al. 1999
16. American Psychiatric Association 1998
11. Grella et al. 2001
17. Cacciola et al. 2001
12. Armstrong and Costello, 2002; Grella et al. 2001; Kandel et al.
18. Regier et al. 1990
1999; Latimer et al. 2002
19. Kessler et al. 1994
13. Grella et al. 2001; Latimer et al. 2002
20. Atkinson and Misra 2002; Cacciola et al. 2001
14. Latimer et al. 2002
21. Weiss and Mirin 1989
15. Gadow and Sprafkin 1999
22. Ciraulo, Piechniczek-Buczek, and Iscan, 2003
16. Latimer et al. 2002
23. Myers et al. 2003
17. Grella et al. 2001
24. Myers et al 2003
18. Glantz 2002
25. Kandel et al. 1999
19. Kessler et al. 1996
26. American Psychiatric Association 1998
20. Glantz 2002; Kandel et al. 1999; Latimer et al. 2002
27. Brady 2001
21. Weiss 1992
28. Jacobsen, Southwick, and Kosten 2001
22. Weiss 1992
29. Dansky et al. 1996
23. Weiss 1992
30. Jacobsen, Southwick, and Kosten 2001
24. Sharp and Getz 1998
31. Brady 2001
25. Gordon 2003; Sinha and Schottenfeld 2001
32. Ouimette, Moos, and Finney 2003
26. McLellan et al. 1983
33. American Psychiatric Association 1998
27. Carroll et al. 1993
34. Kandel et al. 1999
28. Gordon 2003
35. American Psychiatric Association 1998
29. Rosenthal and Westreich 1999
36. Horner and Scheibe 1997
12. Kosten and Kleber 1988
46. Holderness, Brooks-Gunn, and Warren 1994
13. Rosenthal and Westreich 1999
47. National Center on Addiction and Substance Abuse at
14. Sinha and Schottenfeld 2001
Columbia University 2003
15. Gordon, 2003; Weiss and Mirin 1989
48. National Center on Addiction and Substance Abuse at
16. Daley and Salloum 2002
Columbia University 2003
17. Daley and Salloum 2002; Litten and Allen 1995
49. National Center on Addiction and Substance Abuse at
18. Daley and Salloum 2002
Columbia University 2003
19. Gordon 2003
50. Gordon et al. 2001; National Center on Addiction and
20. Daley and Salloum 2002
Substance Abuse at Columbia University 2003
21. Sinha and Schottenfeld 2001
51. Gordon et al. 2001
22. O’Connell 2002
52. American Psychiatric Association 1998
23. Daley and Salloum 2002; Weiss, Mirin, and Frances 1992
53. Salloum, Moss, and Daley 1991
24. Najavits 2002
54. Cacciola et al. 2001; Wolford et al. 1999
25. Najavits 2002
55. Salloum, Moss, and Daley 1991
26. Najavits 2002
56. Salloum, Moss, and Daley 1991
27. Rosenthal and Westreich 1999
57. Wolford et al. 1999
28. Daley and Salloum 2002
58. Cacciola et al. 2001
29. Daley and Salloum 2002; Rosenthal and Westreich 1999
30. Montgomery, Miller, and Tonigan 1995
Section III: Addiction and
Mental Health Treatment
31. Rosenthal and Westreich 1999
1. Cacciola et al. 2001
2. Rosenthal and Westreich 1999
Section IV: Addiction and Mental Health
Treatment at the Caron Foundation
3. Sheehan and Owen 1999
1. Derogatis 1994
4. Rosenthal and Westreich 1999
5. Drug and Alcohol Information System 2002
6. Karageorge 2002
7. Roeloffs et al. 2001
8. Gordon and Troncale 2002
37. Gordon, Tulak, and Troncale, in press
Section II: Common Co-Occurring
Psychiatric Disorders
1. Derogatis 1994
38. Biederman et al. 1995
39. Marshall, Molina, and Pelham 2003
40. Horner and Scheibe 1997; Wilens, Biederman,
and Spencer 1996
2. American Psychiatric Association 1998
3. American Psychiatric Association 1998
4. American Psychiatric Association 1998
41. Cantwell 1996
42. Gordon, Tulak, and Troncale, in press
43. American Psychiatric Association 1998
24
25
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