I’d like to let everyone know in advance this is a fairly long article and actually reads more like an essay or research paper. This is a topic I find absolutely vital to holistic wellness – particularly one’s emotional, mental and physical wellness. I did so much research while writing this that I included a references section at the end for those of you who are interested in learning more about substance abuse in the context of concurrent disorders. These diseases affect the chemistry of the brain and have a lot to do with lacking neurotransmitters as well as studies using bio-markers. These topics are beyond the scope of this article but please keep in mind that it is because of the physical state of the human brain that these disorders exists and that a vicious cycle is so likely to play out. Please read on.

Holistic wellness cannot be realized while an addiction or mental illness has taken hold of somebody. It is important we take a look at evidence on the complex interconnection between addiction and mental illness, and identify important areas that require action in order to improve care and patient outcomes. For the sake of this article, we will define substance abuse as “a maladaptive pattern of substance use defifined by DSM-IV as resulting in recurrent and signifificant adverse consequences related to the repeated use of a drug. Substance abuse is not characterized in terms of tolerance and withdrawal; instead, it includes only the harmful consequences of repeated use, as when that use causes failure to fulfifill obligations at work, school or home, becomes physically hazardous, or creates legal, social or interpersonal problems.” (A Wellness Way of Life 2002) This will be an in depth look at substance abuse and several possible concurrent disorders.

Concurrent disorders — cases in which a person has both a mental health and substance use problem — are a major health issue, with more than 50% of those seeking help for an addiction also experiencing a mental illness, and 15–20% of those seeking help from mental health services also living with an addiction. (Canadian Center on Substance Abuse 2009) These individuals present some of the most complex and difficult-to-treat cases and consume a significant portion of health care services. In both Canada and the USA the systems of care for concurrent disorders are fragmented and compartmentalized — with varying treatment approaches and programs developed on a paradigm that treats either the addiction or mental health issue exclusively as the primary focus — creating a system that is not well equipped to treat both disorders concurrently and results in poor patient outcomes and system inefficiency.

Being turned away by programs because of the existence of one issue or another used to be a common occurence for those seeking treatment for both an addiction and a mental health issue. It was quite common for those seeking treatment for depression or anxiety to be turned away if there was any indication of an existing addiction. The opposite was also true in some cases; the existence of treatment for a mental health issue would prevent workers from helping with an addiction.

Increasing evidence suggests that concurrent disorders have a strong developmental trajectory with onset occurring during adolescence — which makes improving the capacity for early detection and intervention all the more imperative. Drugs used today are more potent, more dangerous and more addictive than ever. Initial drug use is also occuring at an increasingly early age. Fifty-seven percent of high school seniors in the United States have used an illicit drug at least once before they finish high school. Thirty-six percent have used an illicit drug other than marijuana.

Young people in today’s society are bombarded with far more stress than generations past and as a result are likely to develop a mental health disorder, an addiction, or both. It’s quite common for young people to start smoking or drinking or doing other drugs as a way to cope with these new found pressures of life rather than develop real, healthy and long lasting coping mechanisms. It’s also been found that youth raised in rural areas are more likely to have used drugs than those who grew up in an urban area. There is also a lot of support for the theory that teenagers who use cigarettes, alcohol, or marijuana – so called gateway drugs – run a greater risk of moving to harder, more addictive substances. Teens who drink are thirty times more likely to use marijuana; teens who drink and use marijuana are seventeen times more likely to use heroin, oxycontin, cocaine and LSD later. (A Wellness Way of Life 2002)

What’s Going on That Causes People to Become Addicts

The Stress Response

A real link between stressful or traumatic events and substance use problems exists — and evidence of its existence is supported by research. Indeed, people who experience stressful events such as child abuse, criminal attack, natural disasters, war, or other traumatic events often turn to alcohol or drugs. The human stress response comprises a wide range of behavioural and biological changes — many of which are adaptive to help us meet the demands placed on us. However, each of us responds to stress differently; events or stimuli seen as stressful by one person may not be stressful to another. In order to achieve holistic wellness it cannot be overstated that proper mechanisms for coping be taught at a young age.

When individuals encounter a potentially stressful situation, first they appraise the event (e.g., asking “Is this event a threat?”). A second appraisal then follows, in which they determine if they have the resources available to cope with the stress. How an event is appraised may be influenced by the characteristics of the event or situation — including its perceived severity. Based on these appraisals, coping strategies are then adopted to contend with the situation. Generally, these fall into three broad classes: problem solving, emotional strategies (emotional expression, self- or other-blame, rumination) and avoidant strategies (avoidance/denial, active distraction, wishful thinking, drug consumption). Other strategies include religious coping or the seeking of social support.

Many people will use a combination of the abovementioned coping strategies. For example, social support-seeking can provide emotional support or a distraction from the stress. It can also yield a source of information or facilitate problem solving, and perhaps even bring forth a financial resource. The importance of social support in coping is widely recognized. It’s not certain whether unsupport (not receiving support when it is expected, or others’ insensitivity to an individual’s needs) or “tough love” can contribute to drug use, but it may be a powerful predictor of substance abuse.

Finally, the chronicity of stress may be especially important in determining unhealthy or negative outcomes. This is significant given that many stressful events or situations are indeed chronic in nature — considering that stress is often followed by worrying and negative thinking. It is believed that responses to chronic, unpredictable stress result in excessive wear and tear on biological systems, leading to behavioural and physiological disturbances that may include substance use. Given the complicated relationship between stress and substance use, preventative interventions or treatment strategies that teach effective stress appraisal and coping methods may have a significant impact on substance use disorders. Effective stress management skills, together with high-quality social support resources could provide an effective first line of defense against substance use and dependence.

Anxiety Disorders

Anxiety disorders are a group of mental health conditions that involve fear, worry or dread as well as unpleasant sensations such as sweating or muscle tension. Often individuals with these conditions will extensively avoid the situations that cause the anxiety. Although everyone experiences anxiety from time to time, when that anxiety begins to interfere with a person’s life (e.g., functioning in one’s job or family life) or causes significant discomfort, that’s when an individual is considered to have an anxiety disorder (Canadian Center on Substance Abuse 2009).

There are a number of anxiety disorders each with its own set of characteristics:

  • Specific phobia involves an excessive fear and avoidance of a particular object or situation. Some common specific phobias involve fears of dogs, heights, flying, and spiders.
  • Social phobia is characterized by an unrelenting and always present fear of being evaluated negatively by other people. It is much more severe than simply being shy; those with social phobia typically avoid social situations such as parties or other social events where they fear they may be the centre of attention.
  • Generalized anxiety disorder involves a more chronic pattern of anxiety that includes tension in the body and constant worry, such as being preoccupied with what might go wrong with one’s finances, health, or work.
  • Panic disorder involves repeated intense episodes of anxiety called panic attacks. These attacks seem to come out of the blue and involve several unpleasant physical sensations including a pounding heart, dizziness, and feeling short of breath. People with panic disorder often report feeling as if they may go crazy or lose control, or worry that they may be dying while they are experiencing a panic attack. When a person with panic disorder avoids situations where escape would be difficult or where they might be embarrassed if they were to panic, they are said to have the additional problem of agoraphobia.
  • Post-traumatic stress disorderPTSD can develop following exposure to an extremely stressful, life-threatening event or trauma such as a motor vehicle accident, military combat, or assault. Post-traumatic stress disorder is characterized by avoidance of reminders of the trauma, emotional numbing such as difficulties experiencing pleasure, excessive arousal such as difficulty sleeping, and re-experiences of the trauma in the form of nightmares or flashbacks.
  • Obsessive-compulsive disorder is characterized by repeated thoughts that the sufferer finds unacceptable. These obsessions can involve, for example, thoughts of being contaminated by germs or concerns that one is unsafe. Obsessive thoughts are typically followed by rituals called compulsions where the individual attempts to reduce the anxiety caused by the obsession. These rituals might involve hand-washing many times a day until hands are raw, or repeated checking that the stove is turned off.

Anxiety disorders occur together with substance use disorders at alarmingly high rates. Surveys of the general population have shown that those with an anxiety disorder are two to five times more likely to have a substance abuse problem that those without an anxiety disorder. Although all anxiety disorders are associated with an increased risk for substance dependence, the rates of having both vary across the different anxiety disorders. For example, panic disorder is most closely associated with alcohol dependence, but generalized anxiety disorder is more closely linked with dependence on drugs other than alcohol. The anxiety disorder least strongly associated with alcohol or drug dependence is specific phobia.

Population surveys consistently show that anxiety disorders are more strongly linked to substance dependence than to substance abuse. This finding is in line with the theory that links anxious personality traits with a particular style of drinking that is more likely to result in dependence. Other types of personality traits — such as sensation seeking — are said to be linked to a style of drinking more likely to result in abuse.

Substance dependence differs somewhat from the previously described substance abuse. It is the more severe of the two disorders. It can involve tolerance — needing more and more of the substance to attain the desired effect — and withdrawal symptoms, such as a pounding heart or dizziness, when a person tries to stop or cuts back use of the substance.

Those with an anxiety disorder were nearly five times more likely to suffer from a substance use disorder involving the misuse of prescription sedative drugs than those with no anxiety disorder. Without the proper pharmaceutical therapy, talk therapy and coping skills it makes good sense that an anxious person would turn to sedative drugs for relief.

The question is, does the substance use cause the anxiety disorder, or does the anxiety disorder lead to self-medicating behaviour? In attempt to determine which of these theories truly explains the co-occurrence of anxiety and substance use disorders, researchers have investigated which disorder appeared first in people affected by both. In a review of these types of studies, it was concluded that in at least three-quarters of those suffering from both disorders, the anxiety disorder developed first. This makes the self-medication theory a more likely explanation for the development of the concurrent disorders in the majority of cases.

Another method to distinguish between the two theoretical pathways to concurrent anxiety and substance use disorders has been to examine whether anxiety persists in those individuals who have quit using substances once their symptoms of withdrawal have subsided. This approach was taken in a recent, large-scale survey of the general population in the US. The results showed that indeed, anxiety did persist in the vast majority of cases, indicating that substance-induced anxiety was actually quite rare.

Mood Disorders

Mood disorders make up a group of mental health conditions characterized by abnormal changes in mood and affect. These disorders are classified according to signs and symptoms as well as the course of illness.

  • Major Depressive Disorder and Bipolar Disorder are considered the major mood disorders. For either MDD or BD to be diagnosed, the symptoms must be substantial enough to significantly affect a person’s functioning. Both are usually episodic, meaning that the people who suffer from them generally recover but may relapse (i.e., have another episode at a later time). Those with MDD or BD experience depression; those with BD also experience periods of mania — a state of extremely elevated mood, high energy, unusual thought patterns and even psychosis.
  • Dysthymia and Cyclothymia are chronic disorders with less severe symptoms than MDD and BD. Dysthymia is characterized by a persistent depressed mood not severe or extensive enough to fit the diagnosis of MDD. Cyclothymia is characterized by mood shifts both up and down, but not as severe as those seen in BD.

Mood disorders make up the single largest group of major psychiatric disorders. Approximately ten to twenty-five percent of women and five to twelve percent of men develop a major depressive disorder at some point, while the lifetime risk for Bipolar Disorder is estimated to be around two percent. Data for the two milder, chronic versions of the mood disorders are less well established. Health Canada estimates the risk of dysthymia over a lifetime is three to sic percent, and the risk of cyclothymia four-tenths to one percent. A number of studies have established that people with mood disorders are more likely to use substances and become dependent than those without mood disorders. Overall, substance use is highest in those diagnosed with Bipolar Disorder.

People using substances are also more likely to suffer from mood disorders. In general, more severe forms of substance abuse (i.e., dependence) have been linked to more severe forms of mood disorders, or vice versa. In other words, as one disorder becomes more severe, the likelihood of experiencing the other disorder increases.

The possible causes of concurrent mood and substance use disorders are many, but two theories receive the most attention: overlapping predisposition and disorder inducing disorder. An overlapping predisposition encompasses the idea of a common vulnerability to both conditions — something about a person that makes him or her prone to both. This could be due to a genetic predisposition (i.e., being born with genes that make both disorders likely), or common environmental factors that influence both disorders. The theory of disorder inducing disorder postulates that one disorder actually causes the other. With this theory, either mood disorders would induce substance use disorders, or substance use disorders would induce mood disorders — or perhaps both could be possible. The evidence seems less clear than with anxiety disorders.

Several heritability studies involving identical and fraternal twins determined an overlapping genetic predisposition may increase the risk of concurrent substance use and mood disorders; however, given the difficulty of identifying specific genes for psychiatric disorders no specific genes making people vulnerable to both conditions have yet been identified.

Given the significant overlap in mechanisms leading to substance use and mood disorders as well as the impact of concurrent substance use and mood disorders on clinical course and outcome, the importance of treating both conditions in an affected individual is obvious. However, our current health care system is struggling to meet this need and provide the best possible care. Because mood disorders are considered mental health conditions best treated by psychiatrists and mental health professionals, and substance use disorders are often not seen as mental health conditions and as such are usually treated by addiction specialists, a number of challenges for patients with both conditions and for the treatment system exist. For example, a patient may not be accepted for treatment of one disorder because the specialist treatment centre does not support patients with the other disorder. Research also tends to focus on patients with one specific disorder — meaning patients with concurrent disorders are not represented in most findings.

This problem has recently received increasing attention, and the need to improve treatment availability for patients with concurrent disorders is becoming better appreciated. To improve care and treatment for such patients, changes to the treatment system are required, including:

  • Improved detection and diagnosis of the concurrent disorder
  • Increased awareness and acceptance of the need to treat both disorders concurrently
  • Increased focus on the development of treatments for concurrent disorders
  • Increased availability of treatment options for these patients

To improve detection, diagnosis and treatment of a second disorder in patients already diagnosed with a first disorder, treatment providers need to be aware of concurrent disorders (i.e., build their professional knowledge). Treatment providers also need to appreciate the importance of the second disorder and be aware of available treatment options (a matter of professional attitude and overcoming stigma). One simple way to avoid missing a concurrent disorder is to make sure the right assessment instruments are available. Given health care professionals’ almost universal lack of time, self-assessment instruments may be a feasible option.

Up to now, one method of dealing with concurrent disorders has been to defer the treatment of the second disorder until after the first has sufficiently improved. Yet it is now considered good practice to treat both disorders at the same time. That said, with treatment providers normally having the expertise to treat one disorder but not necessarily the other, simultaneously treating both can pose a big challenge. There is a need not only to promote good practice but also to train professionals who are in a position to give treatment for both mood and substance use disorders — at the same level of expertise.

The Vicious Cycle

Substance use helps people deal with the emotional pain, the bad memories, their poor sleep and their guilt, shame, anxiety and terror, and mood disorders. Unfortunately, their use of drugs and alcohol can often lead to a self-perpetuating cycle—their original stress or trauma led to substance use, which then resulted in further stress and trauma in their lives which, ultimately, leads to further substance use — and the stress-substance use cycle continues. In fact, their drug use becomes a “stress proliferator”. The distress associated with substance use is not limited to those consuming drugs or alcohol; substance use often creates significant problems for family and friends, as well — the very people who might otherwise help a person to stop drinking or taking drugs if their relationship hadn’t been undermined by the substance use.

The unique challenges of vulnerable populations with substance use and mental health disorders cannot be overlooked. Through their limited ability to cope with everyday challenges and the stigma attached to their conditions, these individuals may become homeless, socially marginalized and criminally involved. For example, in a police survey through the Vancouver Police Department in the Downtown Eastside, 50% of all emergency calls were found to involve mentally ill and/or addicted people. Only by addressing these challenges can any approach to concurrent mental health and substance use disorders be successful.

References

American Psychiatric Association. (2000).

Diagnostic and statistical manual of mental

disorders (4th ed., text revision).

Washington, DC: Author.

Kalant, H., Grant, D., & Mitchell, J. (Eds.).

Drug abuse and drug dependence. (2007)

In H. Kalant, D. Grant & J. Mitchell (Eds.),

Principles of Medical Pharmacology (7th ed.),

(Chap. 70) Toronto: Elsevier Canada.

McGraw-Hill Higher Education. (2002).

A Wellness Way Of Life (5th ed.),

New York, NY: Author.

Robbins, G., Powers, D., Burgess, S. (Eds.)

Canadian Center on Substance Abuse. (2009)

Concurrent Disorders: Substance Abuse in Canada,

Ottawa, ON: Author.

Krausz, M., Abizaid, A., Stewart, S., Schotz, C. (Pdf)

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