It is difficult to deal with any of these issues on its own, however, when both are presented, figuring out the best approach to treatment can be confusing and difficult. Both substance abuse and mental health problems can be chronic, recurring, and requiring some immediate interventions and ongoing monitoring and support. Mental health symptoms may be exacerbated by substance use, or vice versa. Hence mornitoring becomes very important. Integration of services is improtant and it becomes about communication, consistency, and coordination of all the various clinicians, attention to the person’s basic needs, tailoring the interventions to the motivational level or ‘stage. So far, there is little evidence in support of residential treatment over intensive outpatient care; Self-help groups such as AA and other 12 Step programs seem to play a critical role in community mental health and addiction systems.
Substance use disorders and mood and anxiety problems often exist together, however, the strength of the association between specific anxiety-related diagnoses and substance use disorders varies considerably. Phobic anxiety disorders and, in particular, panic disorder with agoraphobia and social phobia, appear to be most highly associated with alcohol use disorders. In addition, the overlap between post-traumatic stress syndrome (PTSD) and substance use disorders is extremely high with estimates of co-occurrence ranging from 12%-59%.The prevalence of post- traumatic stress syndrome amongst people with substance use disorders is higher for women than men and estimated to range from 30-59%.
The growing awareness of substance-induced mood and anxiety disorderssuggests that for many people the effective treatment of their substance abuse would alleviate the symptoms of the mood and anxiety disorders. Post-traumatic stress disorder is an anxiety disorder which involves a cluster of symptoms characterized by a strong tendency to avoid emotion. Post-traumatic stress syndrome may occur as a consequence of experiencing a severe and stressful life event. Simple post-traumatic stress syndrome may result following a single traumatic event whereas complex post-traumatic stress syndrome arises from repeated incidents of trauma and is associated with a broader range of symptoms. An integrated approach to treatment/support is recommended, with the exception of post-traumatic stress syndrome (PTSD), and in the context of this integrated approach, a sequencing of the specific intervention (beginning with the substance abuse) is recommended, accompanied by ongoing assessment and adjustment of the treatment plan if the mood and anxiety disorder does not improve following an improvement in the substance use disorder. For post-traumatic stress syndrome an integrated treatment approach that deals with both the post-traumatic stress syndrome and substance abuse at the same time is recommended. The best current evidence for the treatment of concurrent substance use and mood and anxiety disorders, including post-traumatic stress syndrome, is cognitive-behavioural treatment (Health Canada)
Whether the interventions are delivered in sequence or concurrently, what are the treatment approaches and interventions for concurrent mood and anxiety disorders and substance abuse that are the most highly supported by research?
Recent reviews, summarizing a large number of well-controlled treatment studies have found overwhelming evidence for the effectiveness of cognitive-behavioural therapy (CBT) for alcohol use disorders, including following components:
- ensuring client choice;
- treating the context of substance misuse;
- tailoring to the person’s stage and motivation for change;
- practical problem-solving;
- emphasis on action;
- reliance on social supports;
- resolving ambivalence about change;
- identifying and managing cues to misuse.
Similarly, with respect to mood disorders an analysis of the depressive symptoms will identify the specific cognitions, behavioral pattern and coping skills that may be maintaining the depressed mood and associated symptoms. Well-described and detailed protocols exist outlining the specific techniques that can modify depressed mood and behavior, including pharmacological treatment.For concurrent depression and alcohol use disorders the evidence also points to CBT as an effective approach.
Despite addressing the alcohol and mood/anxiety symptoms, some individuals may require ongoing relapse prevention, case management and booster sessions. These would include the clients who have difficulty coping with chronic stress or negative life events; occasionally succumb to drinking cues; display less than effective interpersonal behavior. For this population, treatment may often be an ongoing process and require the use of a wide variety of modalities and services (e.g., family therapy, vocational counseling, stress management, lifestyle re-education), in addition to direct treatment of their alcohol abuse and mood/anxiety symptoms. Individuals with concurrent personality disorders often fall into this category.
For individuals who demonstrate serious impairment in several areas, such as work or school, family relations, judgment, thinking or mood, a close and ongoing monitoring of functioning is required as the recovery from substance use disorder may not eliminate the serious impairment in functioning. These individuals remain particularly vulnerable to problematic life events due to their poor coping skills. Suggesting and enabling them to come for additional support when they experience significant stress will probably be a useful preventive strategy. With those individuals who have significant impairments in functioning, considerable vigilance should be exercised for those whose substance abuse is not improving. For them, the various risks associated with mood/anxiety disorders remain. For example, as noted earlier, the risk of suicide under acute intoxication is high.There is also an increased risk of domestic violence,child neglect,child abuse, etc.
Najavits et al.and Najavitswere the first to develop and evaluate a cognitive-behavioral approach within a concurrent, integrated model. Participation in their program, known as “Seeking Safety”, was associated with high retention rates, and reduced substance use as well as post-traumatic stress syndrome symptoms.This treatment program is probably the most widely studied for this population and is currently being evaluated in eight different subgroups for concurrent post-traumatic stress syndrome and substance use disorder. The “Seeking Safety” treatment is designed for clients in the first stage of recovery in which the goal is to reduce substance use and post-traumatic stress syndrome symptomatology. The treatment seeks to:
- increase clients’ knowledge of both disorders;
- enhance life structure and increase coping skills in the management of painful affect; and
- enhance self-care and interpersonal relationships.
There is a small literature on pharmacologic treatment tailored specifically to people with concurrent mood/anxiety and substance use disorders. While some alternatives are beginning to show promise there is insufficient evidence at present for a best practice recommendation. Fluoxetine has been shown to possess relaxing effects in people with substance use disorders that were also diagnosed with social phobia and panic.Tollefson, Montague-Clouse & Tollefson270 found that buspirone reduced alcohol use among people with concurrent anxiety disorders. Kranzler et al.204 found similar results. The use of benzodiazepines is generally cautioned against due to the risk of cross-addiction20 unless the individual has been abstinent for a stable period. While traditional tricyclic anti-depressants effectively treat the depression, they do not impact on alcohol consumption. Fluoxetine (a selective serotonin re-uptake inhibitor) reduced mood symptoms and alcohol consumption in people with alcohol dependence who were clinically depressed.Kranzler et al. found similar results for fluoxetine and naltrexone. There is some evidence for the use of naltrexone in the management of alcohol abusefor people with concurrent mood/anxiety disorders.
In the past decade there has also been some evidence that pharmacotherapeutic interventions can be effective in reducing symptoms associated with post-traumatic stress syndrome and substance use disorders. Trotter et al.279 observed positive results in a 12- week trial of sertraline in an alcohol dependent sample of individuals (two-thirds female) with co-occurring post-traumatic stress syndrome. The results indicated significant reductions in post-traumatic stress syndrome symptomatology, substance abuse and symptoms of depression.
source Health Canada