Treating Co-occurring Substance Abuse and Mood Disorders
Hello. I'm Stephen M. Strakowski, professor of psychiatry, psychology, and biomedical engineering at the University of Cincinnati, where I also serve as senior vice president and chief strategy officer for the affiliated health system University of Cincinnati Health.
Today I want to talk about the co-occurrence of substance abuse disorders with mood disorders, a common clinical problem. While this discussion could also be relevant to substance abuse co-occurring with anxiety or other mental health conditions, I will use mood disorders as my primary example.
Substance use disorders very commonly co-occur with mood disorders, particularly bipolar disorder, where rates are as high as 40%-60% at some point in patients' lives. In depressive disorders, substance use rates are not quite as high, but at 30%-40% are about twice the rate in the general population.[1,2]
Distinguishing Between Disorders and Symptoms
The interactions between co-occurring mood disorder and substance use disorder are very complex. There is a historical view that people with mood disorders use drugs and alcohol to self-medicate. But if you look at studies in which the temporal courses of symptoms have been examined, that really doesn't seem to hold true in most patients.
In fact, the addictive process and development of dependence transcend even the positive reinforcement properties of drugs and alcohol, and often result from a lot of other contextual and negative experiences associated with stopping use of drugs and alcohol. The idea that people are using substances to medicate themselves is in fact true only in a small number of patients.
If you look at the possibility that drugs and alcohol are causing symptoms, or that drugs and alcohol result from the mood disorder or from their shared risk factors, we see that all three possibilities contribute to the elevated rates.
It's often very difficult to know, for each patient, whether there is a causal relationship between the two conditions or no relationship at all. With that in mind, we really have to think about managing both of the co-occurring conditions as separate entities in many cases. This is particularly true because there are relatively few treatments that are effective both for mood disorders and for drug and alcohol use disorders, so it's hard to use one strike to manage both things.
When we think about managing co-occurrence, there are several useful guidelines. I have illustrated them in this slide. It is important to remember that this is a common co-occurrence and to be sure to investigate drugs, alcohol, and mood symptoms, depending on what the patient presents with. If someone is presenting with a mood disorder, be sure to examine the use of drugs, alcohol, and smoking. The converse is also true: If someone is seeking treatment for drug or alcohol abuse, don't forget to investigate the occurrence of a mood disorder. Mood disorders are also elevated in primary drug and alcohol users.
I have mentioned smoking a couple of times; cigarette use is associated with increased anxiety and even higher suicide rates in these individuals, so it can't be minimized and needs to be tracked. I strongly recommend that as you work with patients with this co-occurrence, that in the process of developing mood charts you include tracking of the use of drugs and alcohol to help you decide whether treatments are effective.
Conditions Intimately Linked
The next step in this process is aggressive management of both conditions. Inadequate management of either the mood disorder or the substance abuse disorder invariably leads to failure, minimal, or nonoptimal outcomes for the other condition. They are intimately linked, and each condition can influence improvement in the other. For example, if someone is depressed, alcohol is a depressive agent that may just continually worsen symptoms. If the drinking persists, it will be hard to tell whether antidepressant treatment is working. Conversely, depression may impair the ability to participate in a 12-step program, worsening the likelihood of sobriety.
Both conditions really need to be examined carefully and managed aggressively. Whenever possible, if a single treatment can be effective for both conditions, that's ideal, but unfortunately it's relatively rare. There are a few examples; for example, bupropion is an effective antidepressant and also helps with smoking cessation, so for that combination, bupropion might be a nice intervention.
Cognitive-Behavioral Therapy and Combination Therapy
Cognitive-behavioral therapy (CBT), which I have talked about in A Guide to Managing Bipolar Disorder, is probably an underutilized intervention. Components of CBT are used both for the management of mood disorders and for drug and alcohol abuse, so that combination can be integrated into CBT. However, CBT is not generally effective across both conditions, so combination treatment is usually the rule. In each case, identify the best way to manage each condition and then apply both treatments together. If someone with bipolar disorder needs aggressive mood stabilizers, CBT will help with that. CBT can also be used for alcoholism, although a 12-step program may also need to be implemented. Develop a program in which the providers are talking to each other to be sure that the patients are using both treatments to maximally improve both conditions.
There are relatively few studies of these combination therapies. The McLean Group under Dr Roger Weiss has looked at some integrative treatments in bipolar disorder with substance abuse, and there has been a publication that sertraline plus naltrexone may be particularly effective for the combination of depression and alcohol abuse. Because there are so few data, sophisticated trial and error is the rule. Keep in mind that you are doing trial and error for both conditions. Don't forget smoking in all of this. Smoking is not an acute intoxicant yet, but it can worsen the course of illness and certainly is bad for health. We always want to keep that in mind, although sometimes I will make that a lower priority—it's the third comorbidity—while I try to manage the other two conditions first.
As you work with patients with this complex co-occurrence, work iteratively. Identify the treatment goals for each of the conditions. Work on sophisticated trial and error for each condition, making as few changes at a time as possible—ideally no more than one at each arm of the treatment to track over time what is working effectively. With drug and alcohol abuse, sobriety is often achieved initially, but relapse is very common. It's very important to track treatment interventions for drug and alcohol abuse that sustain sobriety and remission. Keep in mind my rule, which is to try to manage these illnesses with three medications or fewer. As you get into more complicated combinations, there is very little literature to guide decision-making, and certainly there is a very high risk for synergistic and additive side effects. The whole process takes time and will require patience on the part of both clinician and patient. Good monitoring with charting and symptom and functional measures ends up being very important to determine whether a specific intervention has been effective.
That said, in studies of bipolar disorder and alcohol abuse, typically the alcohol abuse in the bipolar patient is not as resilient or persistent as it is in primary alcoholics. So the expectation should be that both conditions can be managed effectively as long as they are attended to. Most patients can have optimal outcomes.
1. Strakowski SM, Nelson EB. Major Depressive Disorder. New York: OAPL Oxford University Press; 2015
2. Strakowski SM. Bipolar Disorder. New York: OAPL Oxford University Press; 2014.
3. Farren CK, Murphy P, McElroy S. A 5-year follow-up of depressed and bipolar patients with alcohol use disorder in an Irish population. Alcohol Clin Exp Res. 2014;38:1049-1058. Abstract
4. Strakowski SM, DelBello MP. The co-occurrence of bipolar and substance use disorders. Clin Psychol Rev. 2000;:191-206.
5. Weiss RD. Treating patients with bipolar disorder and substance dependence: lessons learned. J Subst Abuse Treat. 2004;27:307-312. Abstract
6. Pettinati HM, Oslin DW, Kampman KM, et al. A double-blind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. 2010;167:668-675.
Strakowski, MD, S. M. (2015, Aug). Treating co-occurring substance abuse and mood disorders. Retrieved from http://www.medscape.com/viewarticle/849178?src=wnl_edit_tpal&uac=192771AZ#vp_1