substance abuse in canada: concurrent disorders · substance abuse in canada: concurrent disorders...

S u b S t a n c e a b u S e i n c a n a d a | d e c e m b e r 2 0 0 9

DisorDersConCurrent

ForewordbyRitaNotarandrea, 01

CanadianCentreonSubstanceAbuse

ForewordbyMichaelKirby, 02

MentalHealthCommissionofCanada

Précis 03

1SubstanceUseandMentalHealthDisorders— 06

AnIntroductiontoConcurrentDisorders (M.Krausz)

2Stress,TraumaandSubstanceUseDisorders 12

(A.Abizaid,H.Anisman,K.Matheson,Z.Merali)

3AnxietyDisordersandSubstanceUseDisorders 20

(S.Stewart)

4 ImpulsivityandSubstanceUseDisorders 30

(S.Cox,M.Leyton)

5MoodDisordersandSubstanceUseDisorders 38

(C.Schütz,A.Young)

6PsychosisandSubstanceUseDisorders 48

(t.George,D.Blank)

7ACalltoAction 58

(F.Vaccarino)

table of

contents

ThisdocumentwaspublishedbytheCanadianCentreonSubstanceAbuse(CCSA)andwasmadepossibleinpartthroughafinancialcontributionfromHealthCanada.TheviewsexpressedhereindonotnecessarilyreflecttheviewsofHealthCanada.

Suggestedcitation:CanadianCentreonSubstanceabuse.(2009).Substance abuse in Canada: concurrent disorders.Ottawa,ON:CanadianCentreonSubstanceAbuse.

Copyright©2009bytheCanadianCentreonSubstanceAbuse(CCSA).Allrightsreserved.

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SubstanceAbuseinCanada:ConcurrentDisordersSubstanceAbuseinCanada:ConcurrentDisorders 11

Substance Abuse in Canadaisavitalbiennialpublication—preparedby the Canadian Centre on Substance Abuse in collaborationwithresearchersandclinicalexperts—thathighlightskeyalcoholanddrugissuesinseriousneedofattention.

Thespotlightforthisreportshinesonconcurrentdisorders—theco-occurrenceofmentalhealthandsubstanceusedisorders.ThisversionofSubstance Abuse in Canadaaimstoensureconcurrentdisordersareconsideredamajorpriorityforseveralreasons:

•ConcurrentdisordersareasignificanthealthissueinCanada—morethanhalfofthoseseekinghelpforanaddictionalsohavea mental illness.These individuals present some of the mostcomplexanddifficult-to-treatcasesandconsumeasignificantportionofhealthcareservices.

•InCanada,oursystemofcareforconcurrentdisordersisfrag-mented and compartmentalized —with varying treatmentapproachesandprogramsdevelopedonaparadigmthattreatseither the addiction or mental health issue exclusively as theprimaryfocus—creatingasystemthatisnotwellequippedtotreat both disorders concurrently and results in poor clientoutcomesandsysteminefficiency.

•Increasing evidence suggests that concurrent disorders have astrong developmental trajectory with onset occurring duringadolescence—which makes improving our capacity for earlydetectionandinterventionallthemoreimperative.

The report was written and developed by CCSA’s ScientificAdvisory Council (SAC)— comprised of prominent Canadianexperts in neuroscience, addiction and mental health—thatassistsCCSAin identifyingnewemergingresearchandclinical

advancements that have the potential to improve Canada’sresponsetoalcoholanddrugissues.Thereportsummarizesstate-of-the-artfindingsandhighlights anumberofkeyareaswhereadvancesinourunderstandingofconcurrentdisordershavepro-videdasolidplatformonwhichtobuildtreatment,research,andeducational efforts to improve care and transform the systemsupportingcare.

IwouldliketotakethisopportunitytothankmembersofSACand their colleagues—led by Dr. FrancoVaccarino—for gener-ously volunteering countless hours to researching, writing andreviewing this report and for continuing to lend their valuablebiomedical, clinical and neuroscience expertise to CCSA. Inaddition,IwouldliketothanktheMentalHealthCommissionfor its commitment towork alongsideCCSA tohelpmobilizeactiontoensuregreatercollaborationandcoordinationbetweenaddictionandmentalhealthservices for thisgroup.Webelievethatbymodelingcollaborationatthenationallevelandcreatingsustainable partnerships to maximize our collective efforts onareas identified in the Call to Action, we will see real changewithinthesystemandimprovedoutcomesforthoseindividualsandfamilieswhoaredealingwithconcurrentdisorders.

ritanotarandrea,DeputyChiefexecutiveofficer

CanadianCentreonSubstanceAbuse

forewordforeword

f o r e w o r df o r e w o r d

22 CanadianCentreonSubstanceAbuseCanadianCentreonSubstanceAbuse

MentalillnessandaddictionareserioushealthmattersthataffectthelivesofthousandsofCanadiansandtheirfamilies.Thetwosharemanyfeaturesandareoftencloselytiedtootherissuessuchasstigma,discrimination,homelessnessandpoverty.Mentalill-nessandaddictionarenotproblemsofmoralweaknessorpersonalfailings:theyareasmuch‘real’ illnessesasheartdisease,cancerandAIDS.

TheStandingSenateCommitteeonSocialAffairs,ScienceandTechnologynotedthesubstantialoverlapbetweenmentalhealthand addiction issues—including the largeproportionof peoplelivingwithbothmentalillnessandaddiction— initsfinalreport,Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada. Research shows thatmorethanhalfofthoseseekinghelpforanaddictionalsohaveamentalillness,and 15to20%ofthoseseekinghelpfrommentalhealthservicesarealso livingwithanaddiction.Ratesareevenhigher for more vulnerable populations and certain mentalhealthproblems.

Peopleseekinghelpforco-occurringmentalhealthandaddictionproblems often have difficulty finding appropriate services.Historically, programs have often required that one disorder,eitheraperson’smentalillnessoraddiction,beidentifiedasthemainoneratherthanrecognizingthatthetwoareinterconnected.Infact,thoseseekingmentalhealthserviceshavefrequentlybeenexcludedfromtreatmentiftheyadmittedtosubstanceuse,andthoseseekingtreatmentforanaddictionhavebeenturneddowniftheyweretakingmedicationforamentalillness.Thechallengestointegratingmentalhealthandaddictiontreatmentandsupportforpeoplewithconcurrentdisordersarenumerous;manysectors

forewordforeword

and jurisdictions are working hard to address these challenges.Thereisapressingneedforresearchtobuildaknowledgebaseforthedevelopmentofstrong,fact-basedprevention,treatmentandsupportservices.

Thisreportrepresentsanefforttogathercutting-edgeknowledgeandstate-of-the-artresearchfindingsthatwillhelpshedlightonthecomplexrelationshipbetweenaddictionandmental illness.TheMentalHealthCommissionofCanadaisencouragedbythesignificantrecentdevelopmentsinthisarea.Newdiscoverieswillleadtomoreeffectivesupportsandservices —improvingthelivesofCanadiansandtheirfamiliesastheyfacetherealitiesofmentalillnessandsubstanceuse.

TheMentalHealthCommissionofCanada and theCanadianCentreonSubstanceAbusearecommittedtoworkingcollabora-tivelytoensurethatservicesandsupportsforthoseconfrontingconcurrentmentalhealthandsubstanceusedisordersareresponsive,effectiveandbetterintegrated.TheMentalHealthCommissionhasrecently released a framework for Canada’s first mental healthstrategy,Toward Recovery and Well-Being.Overthenexttwoyears,wewillbedevelopingastrategytoachievethevisionandgoalsoutlinedintheframework.WelookforwardtoworkingwiththeCanadian Centre on Substance Abuse and others to ensure theinclusion of the needs of those living with concurrent mentalhealthandsubstanceuseproblems.

MichaelKirby,Chair

MentalHealthCommissionofCanada


p r é c i Sp r é c i S

Substance Abuse in Canada isabiennialpublicationlaunchedbytheCanadianCentreonSubstanceAbusein2005.Itspurposeistodrawattentiontokeycontemporarysubstanceabuseissuesinthis country and highlight areas for action in both policy andpractice.Eacheditionisdevelopedthroughareviewandanalysisofthelatestresearchevidenceandistargetedprimarilyatpolicymakers,programdevelopmentpersonnel,researchers,educatorsand health professionals. Health journalists also make up animportantreadershipofthisreportastheyraisethepublicprofileoftheissuesandhelpcreatetheimpetusforchange.

t h e S to ry u n t i l n ow t h e S to ry u n t i l n ow

ThefirstSubstance Abuse in Canada report, Current Challenges and Choices,lookedatarangeoftopicsincludingnewdirectionsinpreventingalcoholproblems,alternativesanctionsforcannabisuseandpossession,drugsanddriving,anddiversionandabuseofprescriptionmedications.Thesecondedition,Focus on Youth, examinedtheprevalenceofsubstanceuseanditsassociatedharmsin the general youth population and among non-mainstreamyouth. It reviewed the range of responses available in Canada,exploredtheunderlyingneurobiologyofsubstanceuseinadoles-cence, and identified a range of gaps in services and areas foraction.Thateditionofthereportledinparttothefundingofafive-yearstrategyonyouthdrugpreventionspearheadedbyCCSA.

t h i S e d i t i o n o f S u b S ta n c e a b u S e i n c a n a dat h i S e d i t i o n o f S u b S ta n c e a b u S e i n c a n a da

Concurrentdisorders—the co-occurrenceofmentalhealth andsubstance abuse problems—are the focus of this 2009 edition.ConcurrentdisordersareamajorhealthissueinCanada.Researchshowsthatmorethanhalfofthoseseekinghelpforanaddictionalsohaveamental illness,and15 to 20%ofthoseseekinghelp

prpr éécisc is

from mental health services are also living with an addiction.Individualswithconcurrentdisordersrepresentthemostcomplexcasesandareoften themostdifficult tocare for,with frequentrelapsesandcrisesbeingthenorm.Itisnotsurprisingthenthattheyconsumeasignificantportionofhealthcare resources and,consequently,representalargeproportionofthecostsofcare.

Duetoindependentandcompartmentalizedmentalhealthandaddictionssystems,manypeoplewithconcurrentdisordersaretreatedfortheirmentalhealthissuesortheiraddictionsbutnotalwaysboth,contributingtopoorcareoutcomes.Seekingamoreeffectivetreatmentapproachandtheimprovementofoverallclientoutcomes,this report assesses the unique features of concurrent disordersandhighlightshowoftenaddictionsandmentalhealthissuesareinterconnected—andthereforerequiredifferentapproaches.

a c h a p t e r - b y - c h a p t e r S u m m a rya c h a p t e r - b y - c h a p t e r S u m m a ry

Substance use and mental health disorders — an introduction to concurrent disordersThischapterintroducessomeofthecharacteristicsofindividualswithconcurrentdisorders—aparticularlyvulnerablegroupoftenmarginalizedinsocietyfortheiraddictionsormentalhealthissuesand associated with poverty, homelessness /unstable housing,highratesofHIV,participationinthesextradeandloweredlifeexpectancy.Thechapterhighlightstheneedforresearchintotheunderlyingmental health conditions andpatterns of substanceuseaswellastheirinteractionsondifferentlevels.Allofthisiscriticaltothedevelopmentofeffectivetreatmentsandinterventions.Researchisalsoneededtoimproveunderstandingofthereasonsforincreasingratesofconcurrentdisordersandwhysometherapiesaresuccessfulforcertainconcurrentdisordersbutnotforothers.


Finally,thechapternotestheneedfornewandinnovativewaysoftrainingandeducatingprofessionalsinevidence-basedspecializedandintegratedcare.

Stress, trauma and Substance use disordersThischapterexaminestherelationshipbetweenstressfulortrau-maticeventsandsubstanceabuse.Exposuretotraumaticeventscanincreasealcoholanddruguse,whichcanleadtonewtrau-maticexperiencesthat,inturn,promptfurthersubstanceuse—perpetuatingthestress-substanceusecycle.Itiswidelyrecognizedthat social support is important in successfully dealing withstressfuleventsorsituations.However,whatmattersmostisnotthequantityofsupport(orsupportresources)onehas,butratherthequalityofthatsupport.Preventativeinterventionsortreatmentstrategiesthatteacheffectivestressappraisalandcopingmethodsmayhaveasignificantimpactonsubstanceusedisorders.

anxiety disorders and Substance use disordersIn this chapter, anxietydisorders are defined asmore stronglyassociated with substance dependence—a more severe problemthan substance abuse, with panic disorders being most closelyassociatedwithalcoholdependence,andgeneralizedanxietydis-ordersmostcloselyassociatedwithdependenceondrugs.Peoplewith both an anxiety disorder and a substance use disorderreceivingtreatmentofoneproblem,withoutalsoaddressingtheother,havepoorshort-termoutcomesandahighriskforrelapse.Co-occurring anxiety and substance use disorders need to beaddressed at the same time to improve treatment outcomes —preferablythroughspecializedintegratedtreatmentapproaches.

impulsivity and Substance use disordersHere the report observes that problems with impulse controlare the single strongest predictors of future substance abuse—withalcoholabuseparticularlycommonamonghigh“sensation-seeking”people. Impulsivebehaviour is also a coreproblem inseveralpersonalityandpsychiatricdisorders,puttingthoseaffectedathigherriskofsubstanceuseproblems.Forexample,individualswithADHD(attentiondeficithyperactivitydisorder)areatelevatedriskforsubstanceabuseandaddiction,especiallythosewhodonotreceiveearlytreatment.Acombinationofpreventative,earlyidentification and treatment strategies can diminish the mostdamagingeffectsofimpulsivityanditsconsequences—includingtheriskofsubstanceuseandaddiction.

mood disorders and Substance use disordersHaving amooddisorder increases the likelihood that apersonwillusedrugsandalcohol.Onthewhole,substancedependenceis linked with mood disorders to a greater degree than eithersubstance abuse or substance use. The clinical course of bothmoodandsubstanceusedisorders(treatmentengagement,thoughts

ofsuicide,homelessness,increasedriskofvictimization)andtheirclinicaloutcomes(lifeexpectancy,suicide,treatmentoutcome)isaffectedwhenthetwoconditionsco-occur.Changestothecurrenttreatmentsystemarenecessaryto improvecare forpeoplewithconcurrent substance use and mood disorders. These changesinclude improved detection and diagnosis, increased awarenessandacceptanceof theneed to treatbothdisorders at the sametime,increasedfocusonthedevelopmentofspecializedtreatmentsforconcurrentdisorders,andincreasedavailabilityoftreatmentoptionsforthesepatients.

psychosis and Substance use disordersThischapterrevealsthatpsychoticdisorderssuchasschizophreniaco-occurwithsubstanceusedisordersatthehighestrateofanymentalhealthcondition.Peoplewithschizophreniaare,forexample,threetimesmorelikelytoalsohaveanalcoholproblemandsixtimesmorelikelytohaveadrugproblemthanthosewithoutamentaldisorder.This isaconcernbecausesubstanceabusecanhastentheonsetofpsychoticdisorders,worsenboththesymptomsandthecourseofillness,andleadtohigherratesofpsychiatrichospitalization and increasedhealth care costs.Changes to thetrainingofmentalhealthandaddictionsstaffandphysicians,andreconfigurationofthehealthcaresystemtobettermeetthecomplexneedsofclientswithbothpsychosisandsubstanceusedisorders,areessentialtoprogressinthisarea.Ideally,pharmacologicalandbehaviouraltreatmentsshouldbecombinedforthetreatmentofco-occurringsubstanceuseandpsychoticdisorders.

a call to actionThischapterdrawsonthethemesexploredintheearlierdiscussions.Itreinforcestheneedforgreatercollaborationandinsomecasesanintegratedapproachtoaddressco-occurringmentalhealthandsubstance use disorders. Such an approach includes integratedclinical care and practice guidelines, a common education andtrainingplatform,collaborativeandintegratedresearchprojects,and system-level integration of specialized concurrent-disorderservices.Thischapteralsohighlightstheneedtopayspecialatten-tion to developmental considerations, as many conditions aredevelopmentallysensitiveandbeginduringadolescence.Aswithanyhealthissue,concurrentdisordersarebesttreatedwithearlyintervention and may even be preventable with awareness ofsub-clinicalindicatorsandotherdeterminantsofvulnerability.Thatbeing so, the importance of early detection and interventionrepresentsathemeinandofitself.Finally,thechapterrevisitstheissueoftraumaandstressasanadditionalriskfactorindevelop-ingconcurrentdisorders,andnotesthereisasufficientbodyofknowledgetobegintodevelopintegratedapproachestopreventionandtreatment.


p r é c i Sp r é c i S

Addiction.Addiction. The term addiction The term addiction is generally applied to patterns is generally applied to patterns of heavy use of psychoactive of heavy use of psychoactive drugs that are taken primarily drugs that are taken primarily for their effects on consciousfor their effects on conscious--ness, mood and perception. ness, mood and perception. In general, addiction has been In general, addiction has been replaced by the more specifireplaced by the more specifi--cally defined term substance cally defined term substance (or drug) dependence. However, (or drug) dependence. However, “addiction” continues to be “addiction” continues to be used widely and is generally used widely and is generally thought of as compulsive use thought of as compulsive use leading to physical symptoms leading to physical symptoms of withdrawal when use is of withdrawal when use is discontinued. For that reason, discontinued. For that reason, it is often equated with it is often equated with physical dependence.physical dependence.

ter minology ter minology notesnotes

Several of the terms used in this document have specific and distinct clinical significance, Several of the terms used in this document have specific and distinct clinical significance, but to avoid repetition have been used here as equivalents. The definitions below are based but to avoid repetition have been used here as equivalents. The definitions below are based on the DSM-IV manual and Chapter 70 “Drug Abuse and Drug Dependence.” on the DSM-IV manual and Chapter 70 “Drug Abuse and Drug Dependence.”

Substance Use Disorders. Substance Use Disorders. Substance use disorders Substance use disorders include disorders related to include disorders related to the taking of a drug of the taking of a drug of abuse, to the side effects abuse, to the side effects of a medication, and to toxin of a medication, and to toxin exposure. In the context of exposure. In the context of this publication, “substance” this publication, “substance” refers specifically to a refers specifically to a drug of abuse. Substance drug of abuse. Substance use disorders can be use disorders can be further sub divided into further sub divided into substance dependence substance dependence and substance abuse. and substance abuse.

Substance Dependence. Substance Dependence. This is also referred to as This is also referred to as “drug dependence” and “drug dependence” and constitutes a cluster of constitutes a cluster of cognitive, beha viour al and cognitive, beha viour al and physiological symptoms physiological symptoms

indicating the individual indicating the individual continues his or her subcontinues his or her sub--stance use despite significant stance use despite significant substance-related problems. substance-related problems. There is a pattern of repeated There is a pattern of repeated self-administration that self-administration that usually results in tolerance, usually results in tolerance, withdrawal and compulsive withdrawal and compulsive drug-taking behaviour. drug-taking behaviour.

Substance Abuse. Substance Abuse. This is This is also known as “drug abuse”; also known as “drug abuse”; a maladaptive pattern a maladaptive pattern of substance use defined of substance use defined by DSM-IV as resulting by DSM-IV as resulting in recurrent and significant in recurrent and significant adverse consequences adverse consequences related to the repeated use related to the repeated use of a drug. Substance abuse of a drug. Substance abuse is not characterized in terms is not characterized in terms of tolerance and withdrawal; of tolerance and withdrawal;

AmericanPsychiatricAssociation.(2000).Diagnostic and statistical manual of mental disorders(4thed.,textrevision).Washington,DC:Author.

Kalant,H.,Grant,D.,&Mitchell,J.(Eds.).(2007).Drugabuseanddrugdependence.InH.Kalant,D.Grant&J.Mitchell(Eds.),Principles of Medical Pharmacology(7thed.),(Chap. 70)Toronto:ElsevierCanada.

referencesreferences

instead, it includes only the instead, it includes only the harmful consequences of harmful consequences of repeated use, as when that repeated use, as when that use causes failure to fulfill use causes failure to fulfill obligations at work, school or obligations at work, school or home, becomes physically home, becomes physically hazardous, or creates legal, hazardous, or creates legal, social or interpersonal social or interpersonal problems. Popularly, the term problems. Popularly, the term “drug abuse” is taken to “drug abuse” is taken to mean substance use, but this mean substance use, but this is not approved of. Jaffe is not approved of. Jaffe (1985) provides the following (1985) provides the following definition: “Drug abuse refers definition: “Drug abuse refers to the use, usually by self-to the use, usually by self-administration, of any drug administration, of any drug in a manner that deviates in a manner that deviates from the approved medical from the approved medical or social patterns within a or social patterns within a given culture.”given culture.”


substance use substance use and mental health and mental health disordersdisorders

AnintroductionAnintroductiontoconcurrenttoconcurrentdisordersdisordersreinhard michael Krausz, md, phd, frcpc universityofBritishColumbia

reinhard michael Krausz, md, phd, frcpc

Dr.reinhardMichaelKrauszDr.reinhardMichaelKrauszisaProfessorofPsychiatry,isaProfessorofPsychiatry,epidemiologyandPublicepidemiologyandPublicHealthattheuniversityofHealthattheuniversityofBritishColumbia,MedicalBritishColumbia,MedicalDirectoroftheBurnabyDirectoroftheBurnabyCentreforMentalHealthandCentreforMentalHealthandAddictionandtheregionalAddictionandtheregionalprogramforComplexprogramforComplexConcurrentDisordersandConcurrentDisordersandFoundingFellowoftheFoundingFellowoftheInstituteofMentalHealthInstituteofMentalHealth

atuBC.HeservesonatuBC.Heservesonseveralinternational,severalinternational,national,provincialandnational,provincialandcity-levelAdvisoryBoards,city-levelAdvisoryBoards,includingtheScientificincludingtheScientificAdvisoryCouncilforCCSA,AdvisoryCouncilforCCSA,theresearchAdvisorytheresearchAdvisoryCounciloftheMichaelCounciloftheMichaelSmithFoundationandCo-SmithFoundationandCo-ChairoftheCollaborationChairoftheCollaborationforChangeinVancouver.forChangeinVancouver.

author bioauthor bio


11

In established market economies such as Canada and the US,mentalhealthdisordersaccountfor43%ofdisabilityand22%ofthetotalburdenofdisease(thesumofprematuredeathandyearslivedwithdisability).Andhavingmorethanonedisorder — espe-cially the co-occurrence of an anxiety disorder—contributes togreaterdisability(Andrews,Sanderson&Beard,1998).Thedis-proportionate disability caused by mental health disorders is aresult,inpart,oftheirearlyageofonset,theirchronicity,andthefactthatonlyaminorityofindividualseverreceivetreatmentfortheir conditions (Alegria et al., 2000). Indeed, while rates ofprofessional care formentalhealthdisorders and substanceusedisordershaveincreasedoverthepast30 years,unmetneedforcarestillremainsasignificantpublichealthconcern.

Itisrecognizedthatthemostcomplexanddifficult-to-treatpatientsoftenuseabroadrangeofsubstancesandsufferfromcoexistingmentalhealthdisorders,yetthecurrenttreatmentparadigmforaddictionandconcurrentmentalhealthdisordersistotreatthemasdistinctentities(Fairbairnetal.,2007;Fulkerson,1999).Itisclearthatfromascientificandclinicalperspective,itisnecessarytomoveawayfromoursinglesubstance,singledisorderpointofviewtoanapproachbuiltuponanunderstandingoftheuseofmultiplesubstancesandtheirinteractionwithco-occurringmental

illness.Thishasimportantimplicationsforfutureresearchexam-iningthebiologicalbasisofaddictionandforthedevelopmentofnovelandeffectiveinterventionstrategiesinavarietyoftreat-mentsettings.

Given thatmuchof the research todate and the existingdrugtreatmentprogramshavetypicallyfocusedononlyonesubstance,the use of multiple substances—such as opiates together withstimulants(amphetamines,crackorcocaine)—posesacomplicatedchallenge.Forexample,neitherthebiologicalnorpsychologicalaspects behind the increasing use of crack among patientsdependentonopiatesarewellunderstood.Nevertheless,currentresearch is telling us that this so-called poly-substance use isexceedingly common—perhaps making it the rule and not theexception.Startingwithbasicresearch,abroader focusbeyondsinglesubstanceuseisneededtoexplorethefactorsthatinfluencesubstanceuse,includingconcurrentmentalhealthdisorders.

V u l n e r a b l e p o p u l at i o n SV u l n e r a b l e p o p u l at i o n S

Theentanglementofsevereaddiction,concurrentmentalhealthconditions andphysical illness togetherwithhomelessness andmarginalizationisbecomingamajorchallengeformetropolitanareas across the country. Inner-city populations—particularly

introductionSubstanceusedisordersoccurringtogetherwithmentalhealthdisordersrepresentamajorhealthprobleminCanada.Withhighprevalencerates,theseconcurrentdisordersarechallengingthesystemofcare(Kessleretal.,2005;McGlynnetal., 2003).Todevelopeffectiveinterventionsthatincludeimportantchangestothetreatmentsystem,itiscrucialthatwebetterunderstandtheunderlyingmentalhealthconditionsandthepatternsofsubstanceuse — aswellastheirinteractionsondifferentlevels(Rush,2002).


thoseinjectingdrugs—areatextremelyhighriskofdrug-relatedharm including HIV infection, hepatitis C infection, seriousbacterialinfectionsandoverdosedeath(Kuyperetal.,2004).Thehighratesofconcurrentmentalhealthdisordersandtheco-useofothersubstancesinthispopulationcontinuetochallengethehealthcareandsocialsystems,andthereforenecessitateresearchthataddressesthesecomplicatedsituations(Kamaletal.,2007;O’toole et al.,2007).For example, it is estimated that 130,000 individuals fulfill the criteria for this condition in BritishColumbiaalone(Pattersonetal.,2007).Vancouver’sDowntownEastside(DES)isinternationallyknownforitsconcentrationofindividualswhoinjectdrugs,consumecrackcocaine,sufferfrommental illness and lack housing (Chase-Project-Team, 2005;Wilson-Bates,2008).

Anothergroupthatrequiresspecialattentioninrelationtodrugabuse,traumaandconcurrentmentalhealthdisordersiswomen.Substance-using mothers and their children are especially vul-nerable in innercitiesandare indesperateneedofcustomizedtreatmentsettingsandsaferhomes.

t h e n e e d f o r r e S e a r c h a n d m o d e l St h e n e e d f o r r e S e a r c h a n d m o d e l S

The Diagnostic and Statistical Manual of Mental Disorders(DSM-IV)isveryusefulindiagnosingmentalhealthandsubstanceusedisorders—buthasitslimitations.Describingsymptomsisagoodstart,butit’snotenough.Weneedtounderstandthereasonsbehind the increasing rates of concurrentdisorders in order todevelopbetterandmoreeffectiveinterventions.Andweneedtodeterminewhycertaintherapiesare successful in treatingsomeconcurrentdisordersbutnotothers.Theneedforfurtherresearchintheseareasisclear.

Descriptivemodelsforconcurrentdisordersmayleadtoabetterunderstandingof theuseof substances tocopewithemotionalpain.Onesuchexample,knownasthe“self-medication hypothesis”,postulatesthatsubstanceuseinpeoplewithmentalhealthdisor-dersisanattempttoself-treattheircondition(Khantzian,1978).ThismodelisdiscussedinfurtherdetailinChapter3.Behaviour

pharmacological modelsmayhelpimproveunderstandingoftheinteractionofbiologyandbehaviouralexperience(suchasstressortrauma),enablinginterventionstobemoreeffectivelytargeted.

Unfortunately, patients with concurrent disorders have largelybeenexcludedfrommainstreampsychiatricoraddictionresearchandscientifictrialstoavoid“muddyingthewaters”— ifsubjectswithbothsubstanceuseandmentalhealthdisordersareincludedinatrial,aretheresultsseenduetothementalhealthdisorder,thesubstanceusedisorder,orboth?Theanimalmodelsusedinaddiction research are often focused on a single condition orsubstance, making their application to more complex clinicalproblems—such as concurrent disorders—difficult. Without asolid, focused research base concurrent disorders are not wellunderstood,andthecareprovidedforthemmaybeinappropriate.Futureinterdisciplinaryresearchincorporatingdifferentscientificperspectivesisnecessarytocontributetoanew,morecompleteunderstandingofthedisordersthatwouldhelpthesystemofcaretofunctionbetterinthefuture.

S y S t e m i c i S S u e S a n d t h e n e e d f o r i n t e g r at i o nS y S t e m i c i S S u e S a n d t h e n e e d f o r i n t e g r at i o n

ThepresentsystemofcareinCanadaisnotpreparedtomeetthechallengeofconcurrentsubstanceuseandmentalhealthdisorders.Thefragmentedandcompartmentalizedsystememploysdifferingtreatmentphilosophiesandlacksthespecializedcapacitytotreatboth disorders simultaneously. People being treated within theaddictions system—whether through substitution programs orresidentialcare—arefrequentlydepressed,traumatizedorsufferingfromothermentalhealthissues.Thosebeingtreatedformentalhealth disorders often are using drugs and alcohol. Yet thesepatients are frequently being treated for only one of their co-occurring disorders. In fact, treatment programs often excludeeither those with substance use or mental health disorders —despitethedisordersbeingcloselyconnected.


a n i n t r o d u c t i o n t o c o n c u r r e n t d i S o r d e r Sa n i n t r o d u c t i o n t o c o n c u r r e n t d i S o r d e r S

It is time to consider amajor reorganizationof thedeliveryofaddictiontreatmentandmentalhealthcareinCanada.Newandinnovativewaysoftrainingandeducatingprofessionalsmustbeincorporatedtoachieveanintegrationofcarebasedonbestevi-dence.Withoutextensivechangestoourcurrentsystemofcare,wewill continue tobeunable tomeet theuniquechallengeofsuccessfully managing concurrent mental health and substanceusedisorders.

t h e roa d a h e a dt h e roa d a h e a d

Bycollaborativelymeetingthechallengesposedinthefollowingfourareas,Canadacanbegintosuccessfullyaddresstheneedsofthosewithconcurrentsubstanceuseandmentalhealthdisorders.

more researchAbetterunderstandingofconcurrentdisordersiscrucialtothedevelopmentofeffectiveinterventions.Moreresearchandbettermodelsareessentialforverypracticalreasons.Forexample,iftraumais determined to be a significant factor in the development ofsubstanceusedisorders,addictiontreatmentcouldsystematicallyaddressit.Infact,ifthiswasthecase,preventingtraumaoreffec-tivelymanagingthosewhohavebeenexposedtotraumacouldpotentiallypreventasignificantproportionofsubstanceusedisor-ders —beforetheyevendevelop.Unfortunately,atthistimeresultsfromclinical researchand indeedthecapacity tocarryout thistypeofresearcharesimplynotavailable.

integrated treatment and interventionsPreventionandtreatmentinterventionsaddressingbothsubstanceuseandmentalhealthdisordersneedtobedeveloped.InkeepingwithA Systems Approach to Substance Use in Canada: Recommendations for a National Treatment Strategy,theintegrationoftraining,servicesandprogramsforsubstanceuseandmentalhealthdisorderswithinhealthcare,mentalhealth,education,socialservice,andcriminaljusticesystemswouldresultinimprovedcare.Theintegrationofaddictionandmentalhealthplanningandserviceswouldreflecttherealityofconcurrentsubstanceuseandmentalhealthdisorders.

p r e Va l e n c ep r e Va l e n c e

Research shows that more than 50% of those seeking Research shows that more than 50% of those seeking help for an addiction also have a mental illness, and help for an addiction also have a mental illness, and 15-20% of those seeking help from mental health services 15-20% of those seeking help from mental health services are also living with an addiction.are also living with an addiction.

d i S a b i l i t y / b u r d e n o f d i S e a S ed i S a b i l i t y / b u r d e n o f d i S e a S e

Mental health disorders account for 43% of disability and Mental health disorders account for 43% of disability and 22% of the total burden of disease (the sum of premature 22% of the total burden of disease (the sum of premature death and years lived with disability) --having more than death and years lived with disability) --having more than one disorder contributes to even greater disabilityone disorder contributes to even greater disability

a S n a p S h ot f ro m b ca S n a p S h ot f ro m b c

•• An estimated 130,000 individuals meet the criteria An estimated 130,000 individuals meet the criteria for concurrent disorders) in British Columbia alonefor concurrent disorders) in British Columbia alone

•• Vancouver Police Department survey in the Downtown Vancouver Police Department survey in the Downtown Eastside showed that 50% of all emergency calls Eastside showed that 50% of all emergency calls were found to involve people with mental illness or were found to involve people with mental illness or substance use problemsubstance use problem


development of new therapy modalities

Thedevelopmentofnewandeffectivetherapiesforsubstanceuseandconcurrentmentalhealthdisorderswillbecomepossibleasourunderstandingofthesedisordersandtheiroverlapincreases.With improvedsystemsofcare,newmedication therapieswillreachthosewhowillbenefitmost.Pharmacotherapieswill,however,becomemorecomplex,especiallyinthebackdropofsignificantdrug interactions and side effects for those who are also beingtreatedforotherhighlyprevalentconditionssuchashepatitisC.Psychosocial treatmentprogramssuchascounsellingandtherapy(Rawson,1985)haveshownthatitispossibletochangesubstanceusebehavioursevenincomplexpopulations.Agoodexampleofa successful approach to the treatment of concurrent disordersexists in milieu therapy, or so-called “recovery houses”, whereappropriateroomforchangeandpeersupportaretheingredientsfor success. But these approaches are merely the beginning ofmoretailoredandstructuredtreatmentprotocolsforconcurrentsubstanceuseandmentalhealthdisorders.

recognizing the challengesTheuniquechallengesofvulnerablepopulationswithsubstanceuseandmentalhealthdisorderscannotbeoverlooked.Throughtheir limited ability to cope with everyday challenges and thestigma attached to their conditions, these individuals maybecomehomeless,sociallymarginalizedandcriminallyinvolved.For example, in a police survey through the Vancouver PoliceDepartment in theDowntownEastside, 50%of all emergencycallswerefoundtoinvolvementallyilland/oraddictedpeople.Onlybyaddressingthesechallengescananyapproachtoconcurrentmentalhealthandsubstanceusedisordersbesuccessful.


AmericanPsychiatricAssociation.(2000).Diagnostic and statistical manual of mental disorders(4thed.,textrevision).Washington,DC:Author.

Boyd,N.,Kinney,J.B.,McLean,C.,Heidt,J.,&Otter,I.(2008).Public Order and Supervised Injection Facilities: Vancouver’s SIS.PresentedtotheExpertAdvisoryCommitteeonSupervisedInjectionSiteResearch,HealthCanada.

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Cottler,L.B.,Schuckit,M.A.,Helzer,J.E.,Crowley,T.,Woody,G.,Nathan,P.,&Hughes,J.(1995).TheDSM-IVfieldtrialforsubstanceusedisorders:majorresults.Drug and Alcohol Dependence,38,59–69.

Fairbairn,N.,Kerr,T.,Buxton,J.A.,Li,K.,Montaner,J.S.,&Wood,E.(2007).IncreasinguseandassociatedharmsofcrystalmethamphetamineinjectioninaCanadiansetting.Drug and Alcohol Dependence,88, 313–316.

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HealthCanada.(2002).Best practices: Concurrent mental health and substance use disorders.Ottawa,ON:Author.

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Kessler,R.C.,Berglund,P.,Demler,O.,Jin,R.,Merikangas,K.R.,&Walters,E.E.(2005).Lifetimeprevalenceandage-of-onsetdistributionsofDSM-IVdisordersinthenationalcomorbiditysurveyreplication.Archives of General Psychiatry,62, 593–602.

Kuyper,L.M.,Hogg,R.S.,Montaner,J.S.,Schechter,M.T.,&Wood,E.(2004).ThecostofinactiononHIVtransmissionamonginjectiondrugusersandthepotentialforeffectiveinterventions.Journal of Urban Health : Bulletin of the New York Academy of Medicine,81, 655–660.

McGlynn,E.A.,Asch,S.M.,Adams,J.,Keesey,J.,Hicks,J.,DeCristofaro,A.,etal.(2003).Thequalityofhealthcaredeliveredtoadultsintheunitedstates.The New England Journal of Medicine,348, 2635–2645.

Network,C.H.A.L.(2005).InjectiondruguseandHIV/AIDSinCanada:Thefacts.CanadianHIV/AIDSLegalNetwork.

O’Toole,T.P.,Pollini,R.,Gray,P.Jones,T.,Bigelow,G.,&Ford,D.E.(2007).Factorsidentifyinghigh-frequencyandlow-frequencyhealthserviceutilizationamongsubstance-usingadults.Journal of Substance Abuse Treatment,33(1),51–59.

Patterson,M.,Somers,J.M.,McIntosh,K.,Shiell,A.,&Frankish,C.J.(2008).Housing and Support for Adults with Severe Addictions and /or Mental Illness in British Columbia.CARMAHSimonFraserUniversity.

Spittal,P.,Hogg,R.,Li,K.,etal.(2006).DrasticelevationsinmortalityamongfemaleinjectiondrugusersinaCanadiansetting.AIDS Care, 18(2),101–8.

Wilson-Bates,F.(2008). Lost in Transition — How a Lack of Capacity in the Mental Health System is Failing Vancouver’s Mentally Ill and draining Police Resources.VancouverPoliceBoard.

Wood,E.,Kerr,T.,Montaner,J.S.,Strathdee,S.A.,Wodak,A.,Hankins,C.A.,etal.(2004).RationaleforevaluatingNorthAmerica’sfirstmedicallysupervisedsafer-injectingfacility.The Lancet Infectious Diseases,4, 301–306.

Wood,E.,Tyndall,M.W.,Lai,C.,Montaner,J.S.,&Kerr,T.(2006).Impactofamedicallysupervisedsaferinjectingfacilityondrugdealingandotherdrug-relatedcrime. Substance Abuse Treatment, Prevention, and Policy,1, 13.

a n i n t r o d u c t i o n t o c o n c u r r e n t d i S o r d e r Sa n i n t r o d u c t i o n t o c o n c u r r e n t d i S o r d e r S


Stress,TraumaStress,Traumaand substance use and substance use disordersdisorders

alfonso abizaid

Dr.AlfonsoAbizaidisDr.AlfonsoAbizaidisanAssistantProfessoratanAssistantProfessoratCarletonuniversity’sneuro-Carletonuniversity’sneuro-scienceInstitute.HisworkscienceInstitute.Hisworkisfocusedontheeffectsisfocusedontheeffectsofmetabolicandstressofmetabolicandstresshormonesonmotivatedhormonesonmotivatedbehavioursincludingfeeding,behavioursincludingfeeding,drinking,sexualanddrug-drinking,sexualanddrug-seekingbehaviours.seekingbehaviours.

hymie anisman

Dr.HymieAnisman,aDr.HymieAnisman,aholderofaCanadaresearchholderofaCanadaresearchChairinneuroscience,isaChairinneuroscience,isaProfessorwithintheInstituteProfessorwithintheInstituteofneuroscienceatCarletonofneuroscienceatCarletonuniversity.Hisresearch,university.Hisresearch,

fundedbyCIHrandnSerC,fundedbyCIHrandnSerC,hasfocusedontheimpacthasfocusedontheimpactofstressorsonvariousbrainofstressorsonvariousbrainneurochemicalprocessesneurochemicalprocessesandimmunefunctioning,andimmunefunctioning,andhowthesemightcomeandhowthesemightcometoaffectpsychologicalandtoaffectpsychologicalandphysicalpathologies.physicalpathologies.

Kimberly matheson

KimberlyMathesonisActingKimberlyMathesonisActingVice-President(researchVice-President(research&International)anda&International)andaProfessorintheDepartmentProfessorintheDepartmentofPsychologyatCarletonofPsychologyatCarletonuniversity.Herresearchuniversity.Herresearchconcernspsychosocialfactorsconcernspsychosocialfactorsthatinfluencethestressthatinfluencethestressresponse,andinterventionresponse,andinterventionstrategiesthatmightmitigatestrategiesthatmightmitigateagainsttheextenttowhichagainsttheextenttowhichstresstranslatesintopathostresstranslatesintopatho--logicaloutcomes.logicaloutcomes.

author biosauthor bios Zul merali

Dr.ZulMeraliistheDr.ZulMeraliisthePresidentandCeoofthePresidentandCeooftheuniversityofottawaInstituteuniversityofottawaInstituteofMentalHealthresearch.ofMentalHealthresearch.HeholdsacademicappointHeholdsacademicappoint--mentswiththefacultiesmentswiththefacultiesofSocialSciencesandofSocialSciencesandMedicineattheuniversityMedicineattheuniversityofottawaandwithCarletonofottawaandwithCarletonuniversity.Hisresearchuniversity.Hisresearchfocusesonhowappetitivefocusesonhowappetitiveandaversiveeventsinfluenceandaversiveeventsinfluencebrainfunctioning.Heisbrainfunctioning.Heisparticularlyinterestedinparticularlyinterestedinunderstandinghowvariousunderstandinghowvarioustypesofstressfulexperiencestypesofstressfulexperiencesprecipitatepathologicalprecipitatepathologicalbehaviourand/ormentalbehaviourand/ormentalillness.illness.

alfonso abizaid Carletonuniversity

hymie anismanCarletonuniversity

Kimberly mathesonCarletonuniversity

Zul meraliottawaInstituteofMentalHealthresearch

acknowledgementstheresearchoftheauthorsissupportedbytheCanadianInstitutesofHealthresearch.


22

i S S u ei S S u e

Areal linkbetween stressfulor traumaticeventsand substanceuseproblemsexists—andevidenceof its existence is supportedbyresearch.Indeed,peoplewhoexperiencestressfuleventssuchas child abuse, criminal attack, natural disasters, war, or othertraumaticeventsoftenturntoalcoholordrugs(Cleck&Blendy,2008;Sinha,2008).Substanceusehelps themtodealwith theemotionalpain,thebadmemories,theirpoorsleepandtheirguilt,shame,anxietyandterror.Unfortunately,theiruseofdrugsandalcoholcanoftenleadtoaself-perpetuatingcycle—theiroriginalstress or trauma led to substance use, which then resulted infurtherstressandtraumaintheirliveswhich,ultimately,leadstofurthersubstanceuse—andthestress-substanceusecyclecontinues.Infact,theirdrugusebecomesa“stressproliferator”.Thedistressassociatedwithsubstanceuseisnotlimitedtothoseconsumingdrugsoralcohol;substanceuseoftencreatessignificantproblemsfor family and friends, as well — the very people who mightotherwisehelpapersontostopdrinkingortakingdrugsiftheirrelationshiphadn’tbeenunderminedbythesubstanceuse.

Clearly,therelationshipbetweenstressortraumaandsubstanceuse is complex. Stressful experiences may increase initial drugintake,contributetoongoingdrugconsumption,andplayapart

in the recurrenceor relapseof substanceuseandaddiction.Tobetter appreciate this relationship, it’s helpful to review howpeoplereacttoanddealwithstressintheirlives.

the Stress responseThehumanstressresponsecomprisesawiderangeofbehaviouralandbiologicalchanges—manyofwhichareadaptivetohelpusmeetthedemandsplacedonus.However,eachofusrespondstostressdifferently;eventsorstimuliseenasstressfulbyonepersonmaynotbe stressful to another.Evenwhenpeoplefind eventsequally stressful, their responses to that level of stress may bequitedifferent.Thus,theharmfulconsequencesofstressmaynotbethesameforeveryone.Theseindividualdifferences—includingthebiologicalfactorsthatcontributetostress-relatedproblems—influenceourresponsestostress.

Whenindividualsencounterapotentiallystressfulsituation,firsttheyappraisetheevent(e.g.,asking“Isthiseventathreat?”).Asecond appraisal then follows, inwhich theydetermine if theyhave the resources available to copewith the stress (Lazarus&Folkman,1984).Howaneventisappraisedmaybeinfluencedbythecharacteristicsoftheeventorsituation—includingitsperceivedseverity(Anisman&Matheson,2005).Basedontheseappraisals,

alisa Alisais20yearsoldandhasbeenusingdrugssincetheageof11.StimulantslikeamphetaminesandcrackwereeasytofindonthereserveinnorthernBCwhereshelivedwithherparentsandfiveothersiblings—andnumerousotherrelatives—inthesametinyhouse.Bothofherparentsexperi-encedsevereproblemswithalcoholandwerelargelyunavailabletoher.Infact,hermotherdrankheavilywhileshewaspregnantwithAlisa.Alisawasonly6yearsoldwhenher12-year-oldcousin,whowasdrunk,forcedhertohavesex.thatwasherfirstexperienceofviolence—butnotthelast.At14yearsofage,AlisaleftthereserveandeventuallyfoundherselflivingonthestreetinVancouver.She,likemanyothers,becameentrenchedinthestreets—sleepinginshelters,with

verylittlesupportandfacingadailystrugglejusttosurvive.Itwasduringthistimethatshefirsttriedinjectingdrugs.theopiateshelpedherbynumbingherpsychologicalpainandhelpinghertoforgetallthathadhappenedtoher.Crackhelpedhertostayalert—somethingapersonlivingonthestreetsneedstobe.now,atage20,AlisaislivinginaSingleroomoccupancy(Sro)—awindowless,sparselyfurnishedroom—inVancouver’sDowntowneastside.Shemakesherlivinginthesextrade,mostlytofinanceherdruguse(survivalsex).Abuseandsufferingremainasdailyoccurrencesinherlife,togetherwithnightmaresandflashbacks.Andyet,despiteallthis,shecontinuestohavehopethatsomehowthingsmightchangeforthebetterinherlife.


copingstrategiesarethenadoptedtocontendwiththesituation.Generally, these fall into three broad classes: problem solving,emotionalstrategies(emotionalexpression,self-orother-blame,rumination) and avoidant strategies (avoidance/denial, activedistraction,wishfulthinking,drugconsumption).Otherstrategiesincludereligiouscopingortheseekingofsocialsupport.

Acopingstrategy,whateverformitmaytake,mayservedifferentfunctions.Forexample,socialsupport-seekingcanprovideemo-tionalsupportoradistractionfromthestress.Itcanalsoyieldasourceofinformationorfacilitateproblemsolving,andperhapsevenbringforthafinancialresource.Infact,theimportanceofsocialsupportresourcesincopingwithstressfuleventsorsituationsiswidelyrecognized;however,whatmattersmostisnottheamountofsupportbutthequalityofthissupport.It’snotcertainwhetherunsupport(i.e.,notreceivingsupportwhenitisexpected,orothers’insensitivitytoanindividual’sneeds)contributestodrugproblems,but it may be a powerful predictor of substance use related tostressandtrauma.

People experiencing stress may also use more than one copingstrategy—eitheratthesametimeoroneaftertheother—andit’softenthiscombinationofstrategiesthatdetermineshowwellapersoncopeswithastressfulevent.Withseverestress,aperson’sabilitytothinkclearlyandlogically(i.e.,theircognitivefunction-

ing)maybe impaired,makingappraisingthesituationdifficultandadoptingeffectivecopingstrategiesnearlyimpossible.Infact,thisimpairedcognitivefunctioningcanevenleadtotheadoptionofineffectiveorcounterproductivestrategies,includingdruguse(Anisman & Matheson, 2005). Finally, there are occasions inwhich it is difficult to know which coping strategies to adopt,simplybecausethesituationisambiguous(e.g.,“Willthebiopsyshowthetumourtobemalignant?”,“Willtheeconomycontinuetodecline?”).

the impact of StressTheimpactofastressfulortraumaticeventisalsoinfluencedbymanyfactors.Amongstthesearethecharacteristicsoftheevent,previousstressfulexperiences(includingthoseencounteredearlyin life), individualdifferencesandvariables suchasgender,ageandgenetics.

Thenatureofthestressfuleventmayinfluencethetypeofchangesthatoccurinthebrain;thisinturnmayinfluencewhetherharmfulorunhealthyeffectsemerge(Meralietal.,2004).Moreprofoundbehaviouralandbiologicalchangeshavebeenshownasaresultofuncontrollable,unpredictablestress(Maier&Seligman,1976).Not surprisingly, ambiguous stressors appear to be particularlyeffectiveinprovokinganxiety,whichcouldcontributetosubstanceuse(Matheson&Anisman,2005).Finally,thechronicityofstressmaybeespeciallyimportantindeterminingunhealthyornegativeoutcomes.Thisissignificantgiventhatmanystressfuleventsorsituationsareindeedchronicinnature—consideringthatstressisoftenfollowedbyworryingandnegativethinking.Itisbelievedthatresponsestochronic,unpredictablestressresultinexcessivewearandtearonbiologicalsystems(McEwen,2000),leadingtobehavioural and physiological disturbances that may includesubstanceuse.

Theexperienceofpreviousstressgreatlyinfluencestheimpactofsubsequent stressful encounters.Ourbiological stress responsescanbe“sensitized”bystress,sothatwhenwearere-exposedtothatsamestressortoanewstressfulevent,thestress-relatedchemical


S t r e S S , t r a u m aS t r e S S , t r a u m a a n d S u b S ta n c e u S e d i S o r d e r S a n d S u b S ta n c e u S e d i S o r d e r S

changes in our brains are exaggerated (Anisman et al., 2003).Such changes can affect the pathways in our brains associatedwith drug taking and relapse (Koob, 2008). Similarly, negativeandstressfuleventsinearlylifemaymaketheadultresponsetostress greater (Heim et al., 2008).Thus, although some of thebiologicalchangesinducedbystressaretemporary,theymay,infact,havefar-reachingrepercussions.

Theinterrelationsbetweenstressfulevents,theirappraisal,adoptedcoping strategies and elicited biological responses are complex.Toaddtothiscomplexity, thecharacteristicsof stressfuleventsandtheresponseofindividualstothoseeventsareever-changing.Those who are flexible with a broad range of coping strategiesandareeitherabletoswitchfromonecopingstrategytoanotheroremploycopingstrategiesincombinationmaybemoreresistantorresilienttothenegativeimpactsofstress(Anisman&Matheson,2005).Butthemostprofoundnegativeimpactsofstresswillbefeltbythosehavingarestrictedrangeofcopingstrategiesandthosewhopersistinadoptingstrategiesthatareineffective.

f u r t h e r e V i d e n c e a n d d i S c u S S i o nf u r t h e r e V i d e n c e a n d d i S c u S S i o n

Stressful experiences lead to a number of changes in brainchemicals,manyofwhichhavebeenimplicatedinpsychologicaldisorders, including substance use and dependence. Multiplechemical pathways in many areas of the brain are influencedby stress, including those that link the hypothalamus to thepituitary and adrenal glands (this pathway and its chemical,corticotrophin releasing hormoneorCRH,areinvolvedinmanyofthehormonalresponseshumanshavetostress).Inanimalmodelsofaddiction,CRHhasalsobeenassociatedwithincreasedcon-sumptionofdrugsofabuse,resistancetostoppingdruguse,anddrugrelapse(Stewart,2000).CRHmayalsoincreaseactivityinbrainpathwaysinvolvedwithrewardprocesses—makinganindi-vidual more vulnerable to the changes caused by alcohol anddrugs (Bonci & Borgland, 2009). In fact, blocking CRH hasbeenshowntoreducetheself-administrationofcocaine,heroinand alcohol as well as blocking stress-induced relapse to thesesamedrugs(Shahametal.,1997;Stewart,2000).

Otherpathwaysandareasofthebrainaffectedbystressarethosefor fear and anxiety (Merali et al., 1998, 2004) and those thatcontributetoappraisalandmotivationalprocesses(Anismanetal.,2008).These toomaycontribute to increased riskof substanceuseandaddiction.Stresscancausechanges inabrainpathwaythat uses the chemical dopamine, and this pathway influencesreward-seekingbehaviours.Thisstress-inducedchangecanleadtoincreasedandsustainedbehaviouralresponsestodrugs—enhancingtheirreinforcingproperties(Saaletal.,2003).

When stress is sufficiently severe anduncontrollable, the brainuses up more of these brain chemicals than it can make.Theresultingdecline in theamountof thesechemicals couldaffectthe brain’s ability to transmit messages —and ultimately affectthoughtsandbehaviour.Withchronicstress,ithasbeenshownthatthebraincanadapttotheselowerchemicallevelsbybecomingmoresensitivetotheamountspresent.However,thisadaptationcanbe slow todevelopandmaynot evenoccur if the stress isintermittent and unpredictable. In this case, behavioural andpsychologicalproblemscanresult —whichmayincludesubstanceuse(Anismanetal.,2008).

Thevariousstagesofsubstanceuseanddependence likely involvedifferentmotivations,brainchemicalsandpathways.Initialdrugconsumption may reflect an attempt to simply feel good.Subsequent use of a drug may be in an effort to alleviate thenegativefeelingsthatareexperiencedintheabsenceofthatdrug(Heilig&Koob,2007;Koob&LeMoal,2008).Theimplicationis thatdrug craving is fundamental in sustaining an addiction.Bothstressfulevents(e.g.,lossofalovedone)andcuesassociatedwithadrug(i.e.,beingintheplacewheredrugswerepreviouslyconsumed)canleadtofurtherdruguse,butmaydosoindifferentways.Drug-relatedcues leadingtodrugcraving involverewardprocessesorpositivefeelings.Cravingbroughtaboutbystressleadstodrugintaketominimizeanegativeemotionalstate(Koob&LeMoal, 2008). Evidence of this can be seen with medicationusedtocurbdrinking;theyaresuccessfulinthefaceofalcohol-relatedcuesbutnotinstressfulsituations.Conversely,medications


thatblockCRH(thebrainchemicalimplicatedinstressreactions)cancurbdruguserelatedtostressbutaren’thelpfulinpreventinguseelicitedbydrug-relatedcues(Liu&Weiss,2002).However,the involvement of these various biological processes may varydependingonthestageof substanceuseanddependence —ini-tiationversusmaintenanceversusrelapse.

AlthoughmuchoftheresearchintosubstanceuseandstresshasfocusedonthebrainpathwaysthatinvolvethebrainchemicalsCRHanddopamine,newresearchsuggestsotherpossiblecon-tributing pathways (Abizaid et al., 2006a; Bonci & Borgland,2009).These include a pathway related to energy balance thatuses thebrainchemicalsghrelin and leptin.The twochemicalsstimulateorsuppressourfoodintakeandarereleaseddependingonwhetherornotmore energy is required.However, they arealsosecretedinresponsetostress(Malendowiczetal.,2007; Lutteret al., 2008) and may affect how the body responds to drugs(Fultonetal.,2006;Hommeletal., 2006;Wellmanetal.,2007).Furtherresearchisalsobeginningtouncovertheroleofevenmorebrainchemicalsintherelationshipbetweenstressandsubstanceuse (Ansiman et al., 2008; Koob & LeMoal, 2008; Bonci &Borgland,2009).Indeed,asresearchcontinues,ourunderstandingofthelinkbetweenstressandsubstanceusewillcontinuetogrow.

c o n c l u S i o n S a n d i m p l i c at i o n S f o r c a n a dac o n c l u S i o n S a n d i m p l i c at i o n S f o r c a n a da

Weknowthattheriskforaddictionisgreaterforindividualswhohaveencounteredstressfulexperiencesearlyinlife.Similarly,adultsexperiencingstressfuleventsarealsovulnerabletosubstanceuseand dependence. And it appears that the relationship betweenaddictionandstressismorethanasimpleco-occurrence;studiesshowthatstresscanactuallycauseorcontributetosubstanceuseand dependence. Stress has also been linked to increased drugcravings.Ineffect,stressfulexperiencesmightnotonlybelinkedtoinitiatingsubstanceuse,butmayalsoinfluencecontinueduseof and dependence on that substance. Given this complicatedrelationshipbetweenstressandsubstanceuse,preventativeinter-ventionsortreatmentstrategiesthatteacheffectivestressappraisalandcopingmethodsmayhaveasignificantimpactonsubstanceuse disorders.Effective stressmanagement skills, togetherwithhigh-qualitysocialsupportresources —whicharelikelynotnor-mallyconsideredpartofadrugpreventionstrategyinCanada—couldprovideaneffectivefirstlineofdefenseagainstsubstanceuseanddependence.

•• The relationship between stressful or traumatic events The relationship between stressful or traumatic events and substance use problems is complicated but supported and substance use problems is complicated but supported by research.by research.

•• Exposure to traumatic events can increase alcohol and Exposure to traumatic events can increase alcohol and drug use, which can lead to new traumatic experiences drug use, which can lead to new traumatic experiences that in turn can lead to further substance use, perpetuating that in turn can lead to further substance use, perpetuating the stress-substance use cycle.the stress-substance use cycle.

•• The human stress response comprises a wide range of The human stress response comprises a wide range of behavioural and biological changes to help us meet the behavioural and biological changes to help us meet the demands placed on usdemands placed on us——but these changes can lead to but these changes can lead to unhealthy or negative outcomes in some people.unhealthy or negative outcomes in some people.

•• Stressful experiences lead to a number of changes in brain Stressful experiences lead to a number of changes in brain chemicals, many of which have been implicated in psychochemicals, many of which have been implicated in psycho--logical disorderslogical disorders——including substance use and dependence.including substance use and dependence.

•• The impact of a stressful or traumatic event is influenced by The impact of a stressful or traumatic event is influenced by many factors, including the specific attributes of the stress, many factors, including the specific attributes of the stress, previous stressful experiences (including those encountered previous stressful experiences (including those encountered early in life), individual differences, and variables such as early in life), individual differences, and variables such as gender, age, and genetics. gender, age, and genetics.

•• The importance of social support resources in successfully The importance of social support resources in successfully dealing with stressful events or situations is widely recognized. dealing with stressful events or situations is widely recognized. However, what matters most is not the amount of support However, what matters most is not the amount of support (or support resources) one has, but the quality of this support.(or support resources) one has, but the quality of this support.

•• Preventative interventions or treatment strategies that Preventative interventions or treatment strategies that teach effective stress appraisal and coping methods may teach effective stress appraisal and coping methods may have a significant impact on substance use disorders.have a significant impact on substance use disorders.

at a glanceat a glance




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Sherry h. Stewart, phd

Dr.SherryH.Stewart,PhD,isDr.SherryH.Stewart,PhD,isaKillamresearchProfessorinaKillamresearchProfessorintheDepartmentsofPsychiatrytheDepartmentsofPsychiatryandPsychologyatDalhousieandPsychologyatDalhousieuniversity.Sheisalsotheuniversity.SheisalsothefoundingDirectoroftheCentrefoundingDirectoroftheCentreforAddictionsresearchatforAddictionsresearchatDalhousie(CArD).Dr.Stewart’sDalhousie(CArD).Dr.Stewart’sresearchachievementsinresearchachievementsininvestigatingpsychologicalinvestigatingpsychological

aspectsofaddictionsandtheaspectsofaddictionsandtheco-occurrenceofemotionalco-occurrenceofemotionalandsubstanceusedisordersandsubstanceusedisordershavereceivedinternationalhavereceivedinternationalrecognition.recognition.

author bioauthor bioAnxietyAnxietyDisordersDisordersand substance use and substance use disordersdisorders

Sherry h. Stewart, phd Dalhousieuniversity


33

i S S u ei S S u e

In thepreviouschapterweexploredhowstressandtraumaarerelatedtosubstanceusedisorders.Forsome,exposuretostressortraumacanalsoexpressitselfintheformofanxiety disorders —agroup of mental health conditions that involve fear, worry ordreadaswellasunpleasantsensationssuchassweatingormuscletension.Oftenindividualswiththeseconditionswillextensivelyavoidthesituationsthatcausetheanxiety(Barlow,2002).Andalthougheveryoneexperiencesanxietyfromtimetotime,whenthatanxietybeginstointerferewithaperson’slife(e.g.,functioninginone’sjoborfamilylife)orcausessignificantdiscomfort,that’swhen an individual is considered to have an anxiety ‘disorder’(AmericanPsychiatricAssociation,2000).

Thereareanumberofanxietydisorders,eachwithitsownchar-acteristics(Barlow,Durand&Stewart,2009).

“Specific phobia involves anexcessive fear andavoidanceofaparticularobjectorsituation.Somecommonspecificphobiasinvolvefearsofdogs,heights,flying,andspiders.”

Social phobiaischaracterizedbyanunrelentingandalways-present fearofbeingevaluatednegativelybyotherpeople.It is

muchmoreseverethansimplybeingshy;thosewithsocialphobiatypically avoid social situations such as parties or other socialeventswheretheyfeartheymaybethecentreofattention.

panic disorder involves repeated intense episodes of anxietycalled‘panicattacks’.Theseattacksseemtocomeoutoftheblueand involve several unpleasant physical sensations including apounding heart, dizziness, and feeling short of breath. Peoplewithpanicdisorderoftenreportfeelingasiftheymaygocrazyorlosecontrol,orworrythattheymaybedying,whentheyareexperiencingapanicattack.Whenapersonwithpanicdisorderavoidssituationswhereescapewouldbedifficultorwheretheymightbeembarrassediftheyweretopanic,theyaresaidtohavetheadditionalproblemofagoraphobia.

generalized anxiety disorderinvolvesamorechronicpatternofanxietythatincludestensioninthebodyandconstantworry,suchasbeingpreoccupiedwithwhatmightgowrongwithone’sfinances,health,orwork.

post-traumatic stress disorder—theconditionJennaissufferingfrom—candevelopfollowingexposuretoanextremelystressful,life-threateningeventor‘trauma’suchasamotorvehicleaccident,

jenna Jenna,a25-year-olduniversitystudent,wassexuallyassaultedtwoyearsagobyaguyshemetataparty— averytraumaticexperienceforher.She’snevertoldanyoneaboutitandcarriesalotofguilt,believingitwasherfault,sinceshe’dhadalittletoomuchtodrink.Sincethen,Jennafindsthatthememoriesofthatnightrunthroughhermindoverandoveragain,whethershe’sawakeorasleep.Sheiseasilystartledandhasdifficultysleeping.Jennausedtoenjoyreading,playingmusicandgoingtopartiesbutnolongerfindspleasureinthoseactivities.Infact,becauseofthepainfulremindersoftheassault,sheavoidsattendingpartieswhenevershecan.thereisone

thingthough,thatJennafindshelpful:alcohol.Afterafewdrinks,shedoesn’tfeelsokeyedupandonedge;shecanevensleep.thealcoholhelpstoblockoutthememoriesofthatnight.Itcanevenmakeherbraveenoughtoventureouttoapartywithfriends.thereisacatchthough.Jennaisfindingthatsheneedsmoreandmorealcoholtoachievethecalmsheisseeking.Andafteranightofdrinking,she’sevenmoreedgyandjumpythanusual.Jennafeelslikeshe’scaughtinadownwardspiral—heranxietyleadshertodrink,butthedrinkingeventuallymakeshermoreanxious.theonlysolutionsheseesatthispointistosimplykeepdrinking.


militarycombat,orassault.Post-traumaticstressdisorderischar-acterized by avoidance of reminders of the trauma, emotionalnumbingsuchasdifficultiesexperiencingpleasure,excessivearousalsuchasdifficulty sleeping, and re-experiencesof the trauma intheformofnightmaresorflashbacks.

obsessive-compulsive disorder is characterized by repeatedthoughtsthatthesuffererfindsunacceptable.These‘obsessions’can involve, for example, thoughts of being contaminated bygerms or concerns that one is unsafe. Obsessive thoughts aretypicallyfollowedbyritualscalled‘compulsions’wheretheindi-vidual attempts to reduce the anxiety causedby the obsession.Theseritualsmightinvolvehand-washingmanytimesadayuntilhandsareraw,orrepeatedcheckingthatthestoveisturnedoff.

Anxietydisordersoccurtogetherwithsubstanceusedisordersatalarminglyhighrates(Stewart&Conrad,2008).Surveysofthegeneralpopulationhaveshownthatthosewithananxietydisor-deraretwotofivetimesmorelikelytohaveanalcoholordruguse problem that those without an anxiety disorder (Kushner,Krueger,Frye&Peterson,2008).Althoughallanxietydisordersareassociatedwithan increasedrisk for substancedependence,theratesofhavingbothvaryacrossthedifferentanxietydisorders

(Kushneretal.,2008).Forexample,panicdisorderismostcloselyassociated with alcohol dependence, but generalized anxietydisorderismorecloselylinkedwithdependenceondrugsotherthanalcohol.Theanxietydisorderleaststronglyassociatedwithalcoholordrugdependenceisspecificphobia(Kushneretal.,2008).

Also worthy of mention are other patterns that have emergedfrom surveys of the general population (Kushner et al., 2008).Oneoftheseinvolvesthedistinctionbetweensubstanceabuseandsubstance dependence(AmericanPsychiatricAssociation,2000).

Substance abuse is the less severeof the two substanceusedisorders and is diagnosed when a person experiences negativeconsequences from substanceuse, suchasgetting infightswhenonehasbeendrinking,orneglectingone’sdutiesduetodrinkingordrugtaking.

Substance dependenceisthemoresevereofthetwodisorders.Itcaninvolvetolerance—needingmoreandmoreofthesubstancetoattainthedesiredeffect—andwithdrawalsymptoms,suchasapoundingheartordizziness,whenapersontriestostoporcutsbackuseofthesubstance.

Population surveys consistently show that anxietydisorders aremorestronglylinkedtosubstancedependencethantosubstanceabuse (Kushner et al., 2008). This finding is in line with thetheorythatlinksanxiouspersonalitytraitswithaparticularstyleof drinking that is more likely to result in dependence. Othertypesofpersonalitytraits —suchassensationseeking—aresaidtobe linked to a style of drinking more likely to result in abuse(Cloninger,1987).

Anotherinterestingpatternemergingfrompopulationsurveysisthatanxietydisordersaremorestronglyassociatedwithproblemsinvolvingdrugsthanwithalcohol —thereasonsforwhichremainunclear.However,asurveyintheUSlookingatanxietydisordersoccurringtogetherwithspecificsubstanceusedisorders(Regieret al., 1990), may offer some clues. For example, this survey


a n x i e t y d i S o r d e r Sa n x i e t y d i S o r d e r S a n d S u b S ta n c e u S e d i S o r d e r S a n d S u b S ta n c e u S e d i S o r d e r S

revealedthatthosewithananxietydisorderwerenearlyfivetimesmorelikelytosufferfromasubstanceusedisorderinvolvingthemisuseofprescriptionsedativedrugsthanthosewithnoanxietydisorder.But,perhaps surprisingly, theywere also almost threetimesaslikelytosufferfromasubstanceusedisorderinvolvingstimulant drugs—like cocaine or amphetamines—than thosewithoutananxietydisorder(Regieretal.,1990).


Why is there suchahighoverlapof anxiety and substanceusedisorders?Onetheoryisthatanxietyleadstotheuseofsubstances.Thisisoftenreferredtoastheself-medicationtheory.Italignswellwith the finding discussed in the previous section—that thosewithananxietydisorderaremorelikelytosufferfromasubstanceusedisorderinvolvingthemisuseofprescriptionsedativedrugs.Thetheorysuggeststhatindividualswithanxietydisordersturnto drugs (including alcohol) that have depressant or calmingeffectsinanattempttoself-medicate(orself-treat)theiranxiety.Indeed, lab-based research has shown that several problematicdrugs for people with anxiety disorders—such as alcohol orprescriptiondrugslikeValiumandXanax— dohaveeffectsthatcan be particularly rewarding for anxious people (MacDonald,Baker,Stewart&Skinner,2000).Amongthesedesirableeffectsaresedation (making one sleepy) and the dampening of arousalsymptoms like sweating and muscle tension. In addition, areviewofepidemiologic,familyandlab-basedstudieshasshownthatalcoholcanactuallyreducethechanceofapanicattack(Cosci,Schruers,Abrams&Griez,2007) in thosewithpanicdisorder/agoraphobiabyreducingfearfulexpectationsandapprehension.Thiscanbeaverystrongreward,sincepeoplewithpanicdisorderaretypicallyextremelyfrightenedofhavinganotherattack.

Asecondtheoryisthattheuseofsubstancesleadstothedevelop-mentofanxietydisorders.Thisisinkeepingwiththeotherfindingdiscussedinthesectionabove—thatthosewithanxietydisorderswerealsoalmostmorelikelytosufferfromsubstanceusedisordersinvolving stimulant drugs like cocaine or amphetamines.Thistheorysuggeststhatthemisuseofdrugswithstimulatingeffects—

suchascocaine—mayperhapstriggeroraggravateanxietydisorders(Kushner, Abrams & Borchardt, 2000). In addition, repeatedwithdrawalfromthesesubstancescanleadtoworseningofanxiety,whichcouldsetthestageforthedevelopmentofananxietydisorder(Schuckit&Hesselbrock,1994).Forexample,researchhasshownthattobaccodependenceis linkedtothedevelopmentofpanicproblems(Zvolensky,Bernstein,Yartz,McLeish&Feldner,2008).

In attempt todeterminewhichof these theories truly explainsthe co-occurrence of anxiety and substance use disorders,researchers have investigated which disorder appeared first inpeopleaffectedbyboth.Inareviewofthesetypesofstudies,itwas concluded that in at least three-quarters of those sufferingfrombothdisorders,theanxietydisorderdevelopedfirst(Kushneretal.,2008).Thismakestheself-medicationtheoryamorelikelyexplanationforthedevelopmentoftheconcurrentdisorders inthemajorityofcases.

Anothermethodtodistinguishbetweenthetwotheoreticalpath-waystoconcurrentanxietyandsubstanceusedisordershasbeento examine whether anxiety persists in those individuals whohavequitusing substancesonce their symptomsofwithdrawalhave subsided.Thisapproachwas taken ina recent, large-scalesurveyofthegeneralpopulationintheUS(Grantetal.,2004).The results showed that indeed, anxiety didpersist in the vastmajorityofcases,indicatingthatsubstance-inducedanxietywasactuallyquiterare.

Supportforthetwodifferentpathwaysseemstovarybythedif-ferentanxietydisorders(Stewart&Conrod,2008b).Forexample,generalized anxiety disorder appears to resolve with effectivetreatmentofco-occurringsubstancemisuse,butthesameisnottrueforsocialphobiaandpost-traumaticstressdisorder(Kushneret al., 2005). This suggests that generalized anxiety disorderoccurringtogetherwithasubstanceusedisorderismorelikelytobe causedby the substance. In contrast, social phobiaorpost-traumaticstressdisorderoccurringtogetherwithasubstanceusedisorderismorelikelytorepresentanattemptatself-medication.


Whenresearchersaskpeoplewithanxietywhether theybelievethey are self-medicating with drugs or alcohol, responses varyacross anxiety disorders. One study of this kind (Bolton, Cox,Clara & Sareen, 2006) revealed that self-medication was leastlikelyamongthosewithaformofsocialphobiawhereindividualsfear speaking in public. In fact, only about 8% of this groupreported self-medicating. However, self-medication was muchmorecommonlyreportedinthosewithamorecomplexformofsocialphobia involvingmultiple social fears.Over20%of thisgroup reported self-medicating.Thedifference is likelydue, atleastinpart,tothegreatersocietalacceptanceoftheuseofalcoholanddrugsasa‘sociallubricant’forpartiesandevents.Thesamelevelofacceptanceisunlikelyfordeliveringatalkorlecturewhileundertheinfluenceofdrugsoralcohol(Kushneretal.,2000).

Whethertheco-occurrenceofanxietyandsubstanceusedisordersisanattemptatself-medicationorinducedbythesubstancemaydepend on the particular substance involved. It has been sug-gestedthatdrugswithdepressantortranquilizingeffectsfitbestwiththeself-medicationpathway,whereasdrugswithstimulanteffects align better with the substance-induced anxiety path(Stewart&Conrod,2008b).Butitmaynotbequitethatsimple.Theboosttoaperson’sfeelingsofwell-beingthatcanresultfrom

f i g u r e 1f i g u r e 1

takingstimulantdrugs likeecstasyorcocainecouldalsoplayaroleinself-medication(Kushneretal.,2008).

Athirdandentirelydifferentexplanationforthehighoverlapofanxietyandsubstanceusedisordersmustalsobeconsidered.Perhapsanindividualsufferingfrombothananxietyandasubstanceusedisorder has a common vulnerability to the two conditions—something about that person makes him or her prone to both(Stewart&Conrod,2008b).Theexactnatureofthisvulnerabilityorpronenessremainstobefirmly identified.However, itcouldbeacommonpersonalitytraitpredisposinganindividualtobothconditions(Stewart&Conrod,2008b),orageneticpredispositionpasseddown through thegenerationsof a family. In fact, twinstudieshaveprovidedsomepreliminaryevidencetosuggestcom-mongeneticcontributions to theco-occurrenceofanxietyandalcoholuse(Tambs,Harris&Magnus,1997).Buttheevidenceisn’tconclusive.Forexample,arecentfamilystudyshowednocon-tributionofalcoholismtoeitherpanicdisorderorsocialphobiainfamilies,despitethetwoanxietydisorderscommonlyco-occurringwithalcoholusedisorders(Low,Cui&Merikangas,2008).

Regardlessofwhichpathwayisinvolvedintheinitialoriginsofconcurrent anxiety and substance use disorders, once an indi-

Substance-Induced Anxiety Enhancement

Self Medication

Anxiety Disorder

Substance Use Disorder

a V i c i o u S c yc l e a V i c i o u S c yc l e

regardlessofwhichpathwayisinvolvedintheregardlessofwhichpathwayisinvolvedintheinitialoriginsofconcurrentanxietyandsubstanceinitialoriginsofconcurrentanxietyandsubstanceusedisorders,onceanindividualhasdevelopedbothusedisorders,onceanindividualhasdevelopedbothdisorders,aviciouscyclemaybeatplaywhereeachdisorders,aviciouscyclemaybeatplaywhereeachdisordermaintainsdisordermaintains——orevenexacerbatesorevenexacerbates——theother.theother.



vidual has developed both disorders, a vicious cycle may be atplay where each disorder maintains—or even exacerbates—theother(seeFigure1)(Stewart&Conrod,2008, 2008b).ThecaseofJennaatthebeginningofthischapterisaperfectexampleofjustthat.Theideaofaself-perpetuatingcyclesuggeststhatifoneweretotreatonedisorderwithoutsimultaneouslyaddressingthesecond, the riskof relapsewouldbeveryhigh.Forexample, ifwe try to address a substance use disorder without helping anindividualtomanagehisorheranxiety,wearelikelytoseethatpersonquicklyrevertbacktousingsubstanceswheneverasevereboutofanxietywasexperienced.And ifwe tried toaddressananxiety disorder without addressing that person’s substancemisuse,it’sdoubtfulthatthetreatmentcouldbeverysuccessful(Stewart&O’Connor, 2009),sinceapersonneedstofullycon-front one’s feared situations in order to effectively treat anxiety(Foa & Kozak, 1986). In fact, research does suggest that whenpeoplewhosufferfrombothananxietyandsubstanceusedisorderentertreatmentforonlyoneoftheirconditions,theoutcomeoftheirtreatmentislessthandesirable.Forexample,havingacon-current alcohol use disorder has been found to predict pooreranxietytreatmentoutcomesforthosewithpost-traumaticstressdisorder(Forbes,Creamer,Hawthorne,Allen&McHugh,2003),social phobia (Bruce et al., 2005), generalized anxiety disorder(Bruceetal.,2005),andpanicdisorder/agoraphobia(Bruceetal.,2005).Moststudiesofthosewithasubstanceusedisorderwhohave received treatmentorwhoarenowabstinent suggest thatthepresenceofaco-occurringanxietydisorderincreasesthelike-lihood of a relapse to substance misuse (Kushner et al., 2005; Driessenetal., 2001;Book,McNeil&Simpson,2005).Indeed,onestudyshowedthattherelapserateforalcoholismfollowingtreatmentwas about30%higher for thosewitha co-occurringanxiety problem compared to those without such a condition(Driessenetal.,2001).Relapsesarecostlytothehealthcaresystem;arecentstudyhasrevealedthatdramatichealthcaresavingscanberealizedinthelongertermbyaddressingco-occurringanxietydisordersinthosereceivingtreatmentforsubstanceusedisorders —evenafterfactoringinthecostsofanxietytreatment(Willingeretal.,2002).Together,thesefindingssuggestthatthetwodisordersneedto

beaddressedsimultaneously,bothtoimprovetreatmentoutcomesforpeoplesufferingfromananxietyandasubstanceusedisorderandtoreducehealthcarecostsassociatedwiththesedisorders.

The study of effective treatments for concurrent anxiety andsubstanceusedisordersisinitsinfancy.Nonetheless,researchinthisareaisgrowingrapidly(Stewart&Conrod,2008b).Severalpromisingapproachesnowexisttotreatingco-occurringanxietyand substance use disorders through simultaneous treatment.Simultaneous treatments involve either twodistinct treatmentsbeingprovidedtoaperson—called parallel treatment—orasingletreatmentbeingdeliveredthatisdesignedtoaddressbothdisordersandtheirinter-relations—calledintegratedtreatment(Zahradnik&Stewart,2008).Forexample,anumberofdifferentintegratedtreatmentshavebeendevelopedandevaluatedforco-occurringpost-traumaticstressdisorderandsubstancedependence(Brady,Dansky, Back, Foa & Carroll, 2001; Najavits, Weiss, Shaw &Muenz, 1998; Riggs, Rukstalis, Volpicelli, Kalmanson & Foa,2003; Triffleman, Carroll & Kellog, 1999; Zlotnick, Najavits,Rohsenow & Johnson, 2003; Riggs & Foa, 2008). Integratedtreatmentshavealsobeendevelopedforconcurrentpanicdisorderand prescription sedative dependence (Otto, Jones, Craske &Barlow,2004a),concurrentpanicdisorderandalcoholdependence(Kushner et al., 2006; Toneatto & Rector, 2008), concurrentpanicdisorderandtobaccodependence(Zvolenskyetal.,2008),and social phobia and alcohol misuse (Stewart & O’Connor,2009;Tran,2008).Aneffectiveparalleltreatmentforobsessive-compulsive disorder and substance abuse disorder has beendevelopedaswell(Klostermann&Fals-Stewart,2008).

An example of an effective treatment for co-occurring anxietyandsubstanceusedisordersliesinanintegratedtreatmentdevel-oped forpatientswithbothpanicdisorderanddependenceonprescription sedative drugs (Otto et al., 2004a). A techniquecalledinteroceptive exposure,commonlyusedinthetreatmentofpanic disorder, was extended to the treatment of medicationdependence. Interoceptive exposure involves repeated exposuretothesensationsthatarecommonduringapanicattack—such


at a gl anceat a gl ance

•• The risk of having a problem with drugs or alcohol is The risk of having a problem with drugs or alcohol is two to five times greater in people with anxiety disorders.two to five times greater in people with anxiety disorders.

•• Anxiety disorders are more strongly associated with Anxiety disorders are more strongly associated with substance dependencesubstance dependence——a more severe problema more severe problem——than than substance abuse.substance abuse.

•• Anxiety disorders are more strongly associated with drug Anxiety disorders are more strongly associated with drug problems than alcohol problems.problems than alcohol problems.

•• Panic disorder is the anxiety disorder most closely Panic disorder is the anxiety disorder most closely associated with alcohol dependence, and generalized associated with alcohol dependence, and generalized anxiety disorder is the one most closely associated with anxiety disorder is the one most closely associated with dependence on drugs other than alcohol.dependence on drugs other than alcohol.

•• In at least 75% of people with both an anxiety disorder In at least 75% of people with both an anxiety disorder and a substance dependence, the anxiety disorder and a substance dependence, the anxiety disorder developed first.developed first.

•• Anxiety disorders resulting from substance use appear Anxiety disorders resulting from substance use appear to be relatively rare.to be relatively rare.

•• In people with both an anxiety disorder and a substance In people with both an anxiety disorder and a substance use disorder, treating one without also addressing the use disorder, treating one without also addressing the other leads to poorer short-term outcomes and a high risk other leads to poorer short-term outcomes and a high risk for relapse. for relapse.

•• Co-occurring anxiety and substance use disorders need Co-occurring anxiety and substance use disorders need to be addressed at the same time to improve treatment to be addressed at the same time to improve treatment outcomesoutcomes——preferably through integrated treatment.preferably through integrated treatment.

asshortnessofbreathandaracingheartbeat—thataresofearedbythosewithpanicdisorder(Ottoetal.,1993).Taperingsedativemedicationsisknowntoproducemanyofthesesamesensations.Otto and his colleagues expanded the use of this technique tohelppatientsinadvancetodealwithnotonlytheirepisodesofpanicbutalsowhattheyarelikelytoexperiencewhiletaperingtheirsedativemedications.Thistreatmentprogramhasbeenshowntobeeffectivebothintreatingthesymptomsofpanicdisorderandin helping patients discontinue their sedative medications(Stewart&Watt,2008).Thisnewapproachappears tobenefitbothoftheco-occurringdisorders(Stewart&O’Connor,2009).


So,whyaren’tsimultaneoustreatmentsforco-occurringanxietyand substance use disorders being used regularly in practice?First, we are at an early stage in examining their effectiveness.Much more research is needed to identify the best treatmentapproaches to tackle this complex set of problems (Stewart &O’Connor,2009).Also,weneedtoovercomeseveralbarriersifweare todevelopand implementeffectiveapproaches forcon-currentanxietyandsubstanceusedisorders(Stewart&Conrod,2008b).AforemostconsiderationisCanada’scontinuedtendencytoseparatementalhealthandaddictionservicesinmosthealthcare programs. This separation poses a major obstacle to thedeliveryofintegratedtreatmentsforindividualswithconcurrentanxiety and substance use disorders, since clinicians in eitherservicearetypicallynottrainedtoassessortreattheotherproblem.Thiswouldseemtofavouraparalleltreatmentapproachaccom-paniedbygoodcommunicationbetweenaddictionandmentalhealthserviceproviders.Butthisapproachpresentsproblemsofitsown.Paralleltreatmentscanbequiteintensiveanddemandingforpeoplewithcomplexconcurrentdisordersrelativetoasingleintegratedtreatment,leadingtohighdrop-outratesorlessthandesirabletreatmentoutcomes(Conrod&Stewart,2005;Randall,Book,Carrigan&Thomas,2008).Inaddition,thosewithcon-currentanxietyandsubstanceusedisordersseetheirtwoproblemsas substantially intertwined (Brown, Stout & Gannon-Rowley, 1998;Stewart,1996).Thus,theseparationoftheirproblemintotwo separate disorders with two separate treatments can seemartificial and confusing to clients with concurrent disorders.From an economic perspective, however, integrated treatmentscan be accomplished more efficiently than parallel treatments(Stewart&Conrod,2008b)—animportantconsiderationinthesetimesoffiscalconstraintandhealthcarecutbacks.



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ImpulsivityImpulsivityand substance use and substance use disordersdisorders

marco leyton, phd McGilluniversity

Sylvia m.l. cox, phd McGilluniversity

Sylvia m.l. cox, phd

SylviaCox,PhDisaresearchSylviaCox,PhDisaresearchfellowattheDepartmentoffellowattheDepartmentofPsychiatryatMcGilluniversity.PsychiatryatMcGilluniversity.SheconductedherPhDinSheconductedherPhDinCambridge(uK),wheresheCambridge(uK),whereshebeganhercareerinvestigatingbeganhercareerinvestigatingneuralmechanismsofreward-neuralmechanismsofreward-relatedbehaviours.Herrelatedbehaviours.Hercurrentresearchspecializesincurrentresearchspecializesincocaineabusewithaparticucocaineabusewithaparticu--larfocusonenvironmentalandlarfocusonenvironmentalandneurobiologicalvulnerabilitiesneurobiologicalvulnerabilitiesindrug-seekingbehaviourandindrug-seekingbehaviourandtheprogressiontoaddiction.theprogressiontoaddiction.

marco leyton, phd

MarcoLeyton,PhDisPresident-MarcoLeyton,PhDisPresident-electoftheCanadianCollegeelectoftheCanadianCollegeofneuropsychopharmacologyofneuropsychopharmacology(CCnP)andanassociate(CCnP)andanassociateprofessorinMcGilluniversity’sprofessorinMcGilluniversity’sDepartmentofPsychiatry,DepartmentofPsychiatry,whereheholdsaWilliamwhereheholdsaWilliamDawsonresearchChair.theDawsonresearchChair.thefocusofhisresearchisfocusofhisresearchistheneurobiologyofaddiction,theneurobiologyofaddiction,andaddiction-relatedneuro-andaddiction-relatedneuro-psychiatricdisorders.psychiatricdisorders.

author biosauthor bios


44

i S S u e i S S u e

Impulsivity – the inclination to act without planning, forethought, or restraint.

Much of our behaviour—the decisions we make, the goals wepursueandtheimportancethatweattachtothem—isguidedbysystemsinthebrainthataresensitivetorewardsandpunishments.Weneedthesesystems;wewouldneverhavesurvivedasaspecieswithoutthem.Rewardsystemactivityfostersourinterestinfood,theopportunitytohavesex,andtheexplorationofthosemoredifficult-to-judge events—the unfamiliar and only potentiallypositiveones.Allofthiscompetesagainstapunishmentavoidancesystem(Carveretal.,2008;Ernst&Fudge,2009;Leyton,2009).

When the reward and punishment systems are in balance, weapproachthegoodandavoidthebad.Thisbalancechangeswithage; adolescents and teenagers tend to have relatively strongerreward seeking traits, while adulthood and middle age bringsproportionately stronger inhibitory ones (Galvan et al., 2006).Regardlessofage,though,thesensitivityofthesesystemsseemstovaryfrompersontoperson.Theseindividualdifferenceshelpform key features of our personalities—making one person anuninhibitedrisk-taker,anothermorecautiousandrestrained.

Forsomeimpulsiveindividuals,theprimaryissueisnotwiththereward-punishmentsystemsbutinsteadwithdifficultysustainingattention. These highly distractible individuals are easily side-trackedandhyper-reactive.Theirattentionaldifficultiescorruptdecision-making abilities, leading toflashdecisions andpoorlythought-outplans.

Poorlythought-outplansarealsoconsideredthehallmarkofanotherformof impulsivity—thosesaidtohavepoor inhibitory control.Theseindividualshavedifficultyholdingbackaresponse(suchaswaitingone’sturn)irrespectiveoftheoutcome(deWit,2009).

Problemswithimpulsecontrolarealsothesinglestrongestpre-dictorof future substanceabuse (Compton,etal.,2007;Perry,2008). In the absence of other difficulties, impulsive or highlyreward-sensitive individuals might be considered outgoing andextraverted,seekersofsensationandnovelty,andexistthiswaywithoutdevelopingproblems.However,whenotherchallengesarepresent (such as childhood abuse or stress coping difficulties),theseindividualsaremorelikelytoengageinriskybehaviours,tryaddictivedrugsandthenusethemfrequently—puttingthemselvesatriskfordevelopingsubstanceuseproblems.Alcoholabuseseemstobeparticularlycommoninthisgroup(Conrodetal.,2000).

brad Brad,a23-year-oldwhosometimesworksinconstruction,describeshimselfasa“funguywholikestohaveagoodtime”.Asachild,hewastheclassclown,alwaysjumpingupfromhisseatandshoutingoutjokes—andalwaysgettingintomischief.now,his“goodtimes”ofteninvolvehigh-riskactivities—hisfavouritebeinghangingoutofthepassengerwindowofaspeedingcartothepointthathishairbrushestheroadbelowhim.He’sfallenoutbeforeandhurthimself,butcontinuestodoitbecauseofthegreatrushitgiveshim.Hedescribestheexperienceas“intenseandfocused”.Besideshangingoutofspeedingcars,Bradhasdiscovered

somethingelsethatgiveshimthegreatestrush:cocaine.Hefeelsthatitisn’taproblemforhim,sinceheonlydoesitacoupleoftimesaweekwhenhe’sdrinking.noteveryoneseesBradasthefun-lovingguyhebelieveshimselftobe.Hisgirlfriend’sparentsdonotapproveofhim.Bradstoleasubstantialamountofmoneyfromthemawhilebackandthey’reconcernedaboutwhathemightdonext.Braddidn’treallythinkaboutwhathewasdoingatthetimehestolethemoneyandhedidapologizeafterwards.Hefindsitdifficulttounderstandwhytheycan’tjustforgiveandforget.Braddoesn’tthinkhisbehaviourisanyproblem—it’sjustpartofwhoheis.


Incomparison,problemswith stimulantandopiatedrugsmaydevelopmorefrequentlyinindividualswhoseformofimpulsivityischaracterizedbyarelativeinsensitivitytopunishment(Conrodetal.,2000).Thismayresultinadiminishedresponsetosocialprohibitions and a relative insensitivity to the (often delayed)adverseconsequencesofthedrugsthemselves.

Attheextremes,personalitytraitscanbecomepersonalitydisorders.Impulsivepersonalitydisorderscantakevariousforms,andcom-monlyoccurinconjunctionwithabroadspectrumofco-occurringproblems. In addition to having behavioural disinhibition, indi-vidualswithimpulsivepersonalitydisordersfrequentlyexperiencedramatic mood swings—including sharp spikes of happiness,depression, anger, self-loathing and thoughts of suicide.Theirpersonalrelationshipstendtobeturbulent,alternatingbetweenintensely good and bad. Substance use and abuse is common,perhapsasanattempttosoothetheiremotionalvolatilityandasareflectionoftheirdifficultymakingsensiblechoices.

In those who are particularly under-sensitive to punishment,antisocialactsarenotuncommon.Theseincludesuchbehavioursaslying,disregardingrules,aggressiveness,irresponsibility,showing

littleregardforothersorremorsefortheiractions.Forsuchpeople,theworldseemsastrangeplace,ruledbysocialconventionsthat,tothem,makelittlesense.Totheoutsider,suchpeoplemayoftenseem cold—even callous and indifferent to the pain of others.Perhapsnotunexpectedly, thenegativeconsequences related todrugabusemeanlittletothem,puttingthematparticularriskforusing substances and developing substance use disorders(Comptonetal.,2007).

Impulsivebehaviourisalsoacoreprobleminseveralotherpsy-chiatricdisorders.Arelativelycommonexampleisattention deficit hyperactivity disorder or ADHD. ADHD occurs in 5 to 10% ofchildren,andischaracterizedbydifficultysustainingattentionalfocusandinrestrainingthoughtsandbehaviours.Thesefeaturesmaybeassociatedwithemotionalorotherbehaviouralproblems.In approximately half of affected individuals, many of theirADHDsymptomscontinueintoadulthood.TheprecisecauseofADHDisunclear,butthereisconsiderableevidencethatADHDinvolvesdysfunctionalactivity in the samebrainpathways thatare also implicated in substance abuse and addiction. Indeed,individuals with ADHD are at elevated risk for substance useproblems(Molinaetal.,2003).


Researchhasidentifiedregionsinthebrainthatregulateimpulsivebehaviours,andtheseregionsformintegratedloopsandnetworks(Phillips et al., 2003; Everitt & Robbins, 2005; Dalley et al.,2008). Particularly important are evolutionarily old systems ofthebrainsuchasthelimbic striatum and amygdalathatinfluenceapproach and avoidance behaviours. More recently evolvedsystems in the brain such as the frontal and prefrontal cortex contribute to more complex cognitive planning functions thatfacilitate focused, selective attention (e.g., the filtering-out ofirrelevantinformation)andtheabilitytoplanbehaviouralstrategiesbasedonpreviousexperience.Together,thesesystemsallowustomakebothsimpledecisions(e.g.,eatbananas,notrocks)andmorecomplexones(e.g.,tonight,justtwobeerinsteadofseven)(Ernst&Fudge,2009).

Substance Abuse in Canada: Concurrent Disorders 33

i m p u l s i v i t y a n d s u b s ta n c e u s e d i s o r d e r s

F i g u r e 2

The image depicts inter-connected regions of the brain that are thought to have important roles in the regulation of impulsive behaviours and susceptibility to drug use. This includes the amygdala (AMG) and both ventral and dorsal parts of the striatum (VS & DS). Together, these regions are thought to provide a pre-conscious impetus to approach or avoid cues that signal reward vs. punishment. In comparison, the medial prefrontal cortex (mPFC), anterior cingulate (AC), and orbitofrontal cortex (OFC) are thought to represent subjective responses to rewards and punishments and regulate the planning of actions—sometimes based on prior experience, sometimes when it is unclear what to do. These cortical regions also provide input to the VS, as do the AMG and hippocampus (Hipp). This latter structure, the Hipp, carries contextual memory information. Together, these regions are thought to coordinate flexible, situation-appropriate, goal-directed behaviour. Figure from Everitt & Robbins, 2005. See also Phillips et al., 2003 and Dalley et al., 2008. Frontal parts of the brain are toward the left side of the figure.

F i g u r e 2

These brain systems are influenced by various factors, including age and drug exposure. For example, recent work suggests that biological changes occurring in adolescence can help explain why the teenage years are peak periods for risk-taking (Galvan et al., 2006). These include (i) a relatively overactive reward system that responds intensely to pleasurable stimuli and events that predict the possibility of pleasure, (ii) an incomplete frontal cortex in the brain, which modulates the approach and avoidance systems, and (iii) a surge in gonadal hormones that brings about optimistic persistence. These three features are thought to account in large part for the increased risk of initiating drug use and various other impulsive behaviours in teens (Chambers et al., 2003).

Aggravating these tendencies further is that many drugs of abuse directly engage the same brain systems involved in impulsivity—turning them on and changing them sometimes in ways that endure for days, months and even years (Robinson & Berridge, 1993; Vezina, 2004; Boileau et al., 2006; Cox et al., 2009; Renthal & Nestler, 2008). These brain changes can interfere with multiple decision-making processes and further increase the tendency to use addictive drugs (Mendrek et al., 1998; Vezina, 2004). The extent of these changes and their persisting effects on behaviours, person-ality traits and problems may depend on the starting point. For

l e g e n d(AC) anterior cingulate

(AMG) amygdala

(DS) dorsal parts of the striatum

(GP) globus pallidus

(Hipp) hippocampus

(mPFC) medial prefrontal cortex

(OFC) orbitofrontal cortex

(Thal) thalamus

(VS) ventral parts of the striatum


f i g u r e 3 f i g u r e 3

VEAR (Vulnerability, Exposure, Addiction, Recovery) VEAR (Vulnerability, Exposure, Addiction, Recovery) highlights two major points. First, while inherited genetic highlights two major points. First, while inherited genetic predispositions are often important, their effects predispositions are often important, their effects depend on the surrounding environment. Second, all depend on the surrounding environment. Second, all of the listed factors can be influenced, providing multiple of the listed factors can be influenced, providing multiple opportunities to alter trajectories. A combination of opportunities to alter trajectories. A combination of social policies, personality-specific prevention strategies social policies, personality-specific prevention strategies and treatment can change individual, familial and and treatment can change individual, familial and social dynamics, altering the course of an individual’s social dynamics, altering the course of an individual’s life path.life path.

some vulnerable individuals, the allure of extensive drug usemightprovetoohardtoresistfromthebeginning.Inothercases,aslightlyimpulsiveindividualmightbecomemoreso.Forbothindividuals,repeatedsubstanceusemightnarrowthefocusoftherewardsystemtowarddrugsanddrug-relatedcues,diminishingtheabilityofothergoalstoattractandmotivatethem(Leyton,2007).

Thecausesofimpulsivetraitsarestillonlypartiallyunderstood.Wedoknow,though,thatthesetraitsclusterinfamilies(Cadoretet al., 1986), and recent models suggest that inherited geneticsusceptibilities are aggravated by prenatal exposure to drugs(including nicotine and alcohol), childhood traumas, and theinfluenceofparentsandpeers(Chapmanetal.,2007).Whetherornotapredispositionto impulsivebehaviours leadstosubstanceuseproblemsdependsonadditionalaggravatingandprotectivefactors(seeFigure3:VEARModelofAddiction).

The interactionsbetween these influencescanbecomplex.Forexample, recent analyses suggest that the behaviour of parentsinfluences which friends their children choose. And, if a childtends to be behaviourally disinhibited, interactions with peerswhousedrugswillsubstantiallyincreasethelikelihoodthatthey,too,willinitiatedruguseandprogresstoaddiction(Chapmanetal.,2007).


t r a n S i t i o n p o i n t S & t r e at m e n t t r a n S i t i o n p o i n t S & t r e at m e n t

ta r g e t S f o r c o - m o r d i d d i S o r d e r S ta r g e t S f o r c o - m o r d i d d i S o r d e r S

t h e V e a r m o d e l o f a d d i c t i o n

g e n e t i cg e n e t i c

p r e n ata lp r e n ata lFetal drug, alcohol & nicotine exposure

c h i l d h o o dc h i l d h o o dNeglect & abuseEducationSocial/family normsADHD/conduct disorders

a d o l e S c e n c ea d o l e S c e n c e

yo u t h - r e l at e d r i S K fac to r S

Hyperactive brain reward systemWeak inhibitory brain systemHigh novelty & sensation seekingPoor impulse control

Social / family normsDrug availability

ADHD/conduct disordersMood & anxiety disordersSchizophrenia & other psychoses

a d u lt h o o da d u lt h o o d

e f f e c t S o f S u S ta i n e d d r u g u S e

Drug-focused brain reward systemFailure to mature inhibitory

brain systemReduced impulse-control &

decision-making abilities

ag g r aVat i n g fac to r SSocial/family normsOther psychiatric disordersDisease / infection (e.g., HIV, HCV)

at t e n uat i n g fac to r S(Harm reduction)Needle exchangeSafe injection sitesCondomsNutritionTreatment of comorbid illnesses

r e c oV e ryAttenuating factors

Treatment:Replacement therapiesAntagonistsTreatment of comorbid

illnessesCognitive Behavior TherapyContingency Management

TherapyProtected residential

environmentsSocial skills trainingJobs skills trainingNeurocognitive function

training

Pre-use factors

VulnerabilityVulnerability

ExposureExposure

RecoveryAddiction

Initiation Abuse Addiction Recovery

VV

ee

aa rr


i m p u l S i V i t y a n d S u b S ta n c e u S e d i S o r d e r Si m p u l S i V i t y a n d S u b S ta n c e u S e d i S o r d e r S

•• Problems with impulse control are the single strongest Problems with impulse control are the single strongest predictor of future substance abuse.predictor of future substance abuse.

•• Alcohol abuse seems to be particularly common in “high Alcohol abuse seems to be particularly common in “high sensation seeking” people.sensation seeking” people.

•• Impulsive behaviour is a core problem in several personality Impulsive behaviour is a core problem in several personality and major psychiatric disorders that put those affected at and major psychiatric disorders that put those affected at higher risk for a substance use disorder.higher risk for a substance use disorder.

•• Individuals with ADHD Individuals with ADHD——an impulsivity-related disorderan impulsivity-related disorder——are at elevated risk for substance abuse and addiction. are at elevated risk for substance abuse and addiction. This may be particularly true for those who do not receive This may be particularly true for those who do not receive early treatment.early treatment.

•• The influence of factors such as age and drug use can affect The influence of factors such as age and drug use can affect the systems in the brain that regulate impulsive behaviours.the systems in the brain that regulate impulsive behaviours.

•• Evidence suggests that inherited genetic susceptibilities Evidence suggests that inherited genetic susceptibilities to impulsivity are aggravated by prenatal exposure to drugs to impulsivity are aggravated by prenatal exposure to drugs (including nicotine and alcohol), childhood traumas, and (including nicotine and alcohol), childhood traumas, and the influence of parents and peers.the influence of parents and peers.

•• A combination of preventative and treatment strategies A combination of preventative and treatment strategies can diminish the most damaging effects of impulsivity and can diminish the most damaging effects of impulsivity and its consequencesits consequences——including the risk for substance use including the risk for substance use and addiction.and addiction.

Druguseduringadolescencemightbeparticularlyproblematic.Accumulatingstudiesshowthattheseindividualsareatelevatedriskfordevelopingsevereaddictionproblems(Chambersetal.,2003).Thismaybeduetotheirrelativelyunderdevelopedbrainstructuresaswellasthelong-lastingbiologicaleffectsofdrugsonthesestill-developingbrainsystems.Indeed,frequentexposurestoaddictivedrugscanincreaseimpulsivebehaviour—ineffectmul-tiplyingfurthersusceptibilitiestosubstanceabuseandaddiction.

Asourunderstandingofthedifferenttypesofimpulsivebehaviourgrows, so too does our ability to effectively target preventioneffortsandtreatment.Forexample,ofthemanytreatmentoptions,twoparticularstrategiesarepromising:

•Forhigh“sensationseekers”cognitive behaviour therapiescandiminish and delay their risk for alcohol abuse (Conrod etal.,2008).

•ForthosewithADHD,medication-based therapiescanhelptomitigate the broad spectrum of substance use problems thattheseindividualsareatincreasedriskfor.Sincethemostcommonmedication treatment for ADHD is the administration ofstimulants—a drug class that itself can be abused—there wasconcern for many years that treatment might aggravate thisvulnerability.Fortunately,compellingevidencenowexiststhattreatingADHD-affectedchildrenwithstimulantdrugsdoesnotincreasetheirtendencytoabusedrugs—stimulantsorotherwise(Wilensetal.,2008).


Impulsivetraitscantakemanyformsandleadtomanyoutcomes,dependingoncircumstances.One“impulsive”personmightbeexcitinganddramaticyetalsoafearlessleaderwhodrawspeoplenear, behaving with courage rather than feckless disregard. Incomparison,anotherindividualstartingfromthesamepredispo-sitions may become rash and unregulated, overly attracted tomood-alteringdrugsandinsufficientlydeterredbydangers.Thefirstmayhavebenefitedfromasupportivefamilywithreasonablechallengesandencouragingopportunities;thesecondmayhavesuffered childhood abuse and neglect. We cannot yet predictwithcertaintywhowillgodownwhichpath,butacombinationofpreventative and treatment strategies candiminish themostdamagingeffectsoftheimpulsivetraitsandtheirconsequences,including the risk for substance use and addiction. Strategiessuchasthesebenefitusall.



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MoodMoodDisordersDisordersand substance use and substance use disordersdisorders

christian g. Schütz, md, phd, mph universityofBritishColumbia

allan h. young, mbchb, mphil, phd, frcpsych, frcpc universityofBritishColumbia

christian g. Schütz, md, phd, mph

ChristianG.SchützholdsChristianG.SchützholdsdegreesinMedicine(universitydegreesinMedicine(universityofFreiburg),PublicHealthofFreiburg),PublicHealth(JohnsHopkinsuniversity)and(JohnsHopkinsuniversity)andChineseStudies(universityChineseStudies(universityofMunich).HecompletedhisofMunich).Hecompletedhisclinicaltraininginpsychiatry,clinicaltraininginpsychiatry,psychotherapyandaddictionpsychotherapyandaddictionmedicineinGermanyandhismedicineinGermanyandhisresearchtraininginpreclinicalresearchtraininginpreclinicalandclinicalbehaviouralpharandclinicalbehaviouralphar--macologyduringfellowshipatmacologyduringfellowshipatnIDA/nIH.HerecentlyjoinednIDA/nIH.HerecentlyjoinedtheInstituteofMentalHealththeInstituteofMentalHealthatBritishColumbiauniversityatBritishColumbiauniversitytostudymechanismsoftostudymechanismsofrelapseinpatientswithsubrelapseinpatientswithsub--stancedependenceandseverestancedependenceandseverementaldisorders.mentaldisorders.

allan h. young, mbchb, mphil, phd, frcpsych, frcpc

ProfessorAllanYoungProfessorAllanYoungcurrentlyholdstheLeadingcurrentlyholdstheLeadingedgeendowmentFundedgeendowmentFundendowedChairinDepressionendowedChairinDepressionresearchintheDepartmentresearchintheDepartmentofPsychiatryattheuniversityofPsychiatryattheuniversityofBritishColumbia,Vancouver,ofBritishColumbia,Vancouver,Canada,whereheisalsoCanada,whereheisalsoDirectoroftheInstituteofDirectoroftheInstituteofMentalHealth.HisresearchMentalHealth.Hisresearchinterestsfocusonthecauseinterestsfocusonthecauseandtreatmentsforsevereandtreatmentsforseverepsychiatricillnesses,particupsychiatricillnesses,particu--larlymooddisorders.larlymooddisorders.



55

i S S u ei S S u e

Mood disorders make up a group of mental health conditionscharacterized by abnormal changes in mood and affect.Thesedisordersareclassifiedaccordingtosignsandsymptomsaswellasthecourseofillness.ThefourmostcommonareMajor Depressive Disorder (MDD),Bipolar Disorder(BD), Dysthymia andCyclothymia.Thefirsttwoareconsideredmajordisorders;foreitherMDDorBDtobediagnosed,thesymptomsmustbesubstantialenoughtosignificantlyaffectaperson’sfunctioning.Bothareusuallyepisodic,meaningthatthepeoplewhosufferfromthemgenerallyrecoverbutmayrelapse(i.e.,haveanotherepisodeatalatertime).Thosewith MDD or BD experience depression; those with BD alsoexperience periods of mania —a state of extremely elevatedmood,highenergy,unusualthoughtpatternsandevenpsychosis.Bipolardisordercanbebrokendownintotwodifferenttypes:BPI(manicanddepressiveepisodes)andBPII(lesssevereor‘mild’mania—calledhypomania —anddepressiveepisodes).

DysthymiaandCyclothymiaarechronicdisorderswithlessseveresymptomsthanMDDandBD.Dysthymia ischaracterizedbyapersistentdepressedmoodnotsevereorextensiveenoughtofitthe diagnosis of MDD. Cyclothymia is characterized by moodshiftsbothupanddown,butnotassevereasthoseseeninBD.

Mooddisordersmakeupthesinglelargestgroupofmajorpsy-chiatricdisorders.Approximately10to 25%ofwomenand 5to12%ofmendevelopamajordepressivedisorderatsomepoint,whilethelifetimeriskforBDisestimatedtobearound2%.MenandwomenareequallylikelytodevelopBDI(maniaanddepres-sion),butwomentendtobediagnosedwithBDII(hypomaniaand depression) more often. Data for the two milder, chronicversionsof themooddisordersare lesswellestablished.HealthCanadaestimatestheriskofdysthymiaoveralifetimeis3to6%,andtheriskofcyclothymia0.4to 1%(Gaveletal.,2005).

AsdiscussedinChapter 3,thetwomajorsubstanceusedisordersaresubstance abuseandsubstance dependence.Anumberofstudieshaveestablishedthatpeoplewithmooddisordersaremorelikelyto use substances and become dependent than those withoutmooddisorders.Overall,substanceuseishighestinthosediag-nosedwithBD(Levin&Hennesy, 2004).Infact,recentresearchshowsthatevenmanicsymptomsnotsevereenoughtocountas“truemania”maystillincreasetheriskofsubstanceusedisorders(Marikangasetal.,2008;Marimmanietal.,2007).Butthat’snotwhere the relationship ends. People using substances are alsomore likely to suffer from mood disorders. In general, moresevere forms of substance abuse (i.e., dependence) have been

claudia Claudia,a39-year-oldeventmanager,hasjustbeenhospitalizedforthefirsttimeaftertellingfriendsthatsheplannedtojumpoffabridgeto“enditall”.Afterarelativelyuneventfulchildhood,Claudiabeganexperiencingpanicattacksasateen.Whileinhighschool,shedrankalcoholandsmokedsomecannabis—butonlyonweekends.Duringcollegeshehadsomedifficultywithlowmoodsandlackofmotivation,buttheseeventuallyresolvedontheirown.Aroundthistimeshestartedusingcannabismoreregularlyandalsousedcocaineontheweekends.onceClaudiafinishedcollegeshetookacelebra-torytriptoeurope.Whenshearrivedthereshefelt“ontopoftheworld”.Shespentallofhermoneywithinthe

firstcoupleofdaysandendedupbeingsenthomeaftergettingarrestedfor“civildisturbance”.ItwasatthispointthatClaudiawasdiagnosedwithbipolardisorder.Sherecoveredandoptednottotakeanymedicationthatwouldhelptopreventfuturemania(highmoodandenergy)ordepression.However,threeyearslateramidstherdailyalcoholandregularcocaineuse,sheexperiencedanothermanicphase.Shebegantakinghermedicationbutstillexperiencedperiodsofmania(althoughlessseverethanbefore).Itwasthefrequentboutsofdepression,however,thatcausedhertoconsiderendingherlifebyjumpingoffthebridge.Shesimplydidnotwanttolivewiththedepressionanylonger.


linkedtomoresevereformsofmooddisorders,orviceversa.Inotherwords,asonedisorderbecomesmoresevere,thelikelihoodofexperiencingtheotherdisorderincreases(Merikangasetal., 1998).

ACanadiansurveyonhealth(CCHS on Mental Health and Well Being) collected information on substance use disorders andMDD.Muchlikeinothercountries,thesurveyfoundthatthosewho had been diagnosed with MDD within the previous 12 monthsweremore likely to report concurrentharmful alcoholuse(12.3%comparedto7%inthegeneralpopulation),alcoholdependence(5.8%comparedto2.6%inthegeneralpopulation),and drug dependence (3.2% compared to 0.8% in the generalpopulation).Thoseexperiencingsubstanceusedisorderswithintheprevious12 monthswerealsomorelikelytoreportaconcurrentMDD (8.8% among alcohol-dependent individuals; 16.1% inindividualsdependentonanillegalsubstancecomparedto4.0%inthegeneralpopulation)(Adlafetal.,2005;Graveletal.,2005).

Havingbothasubstanceusedisorderandamooddisorderhasanimpactonbothmorbidity(i.e.,experiencingillnessorharm)andmortality(i.e.,dying).Havingamoodandasubstanceusedisorder can negatively impact a person’s clinical course (i.e.,theirexperienceofillness)andtheirclinicaloutcome(including

life expectancy and treatment outcomes). For example, studieshave shown thenegative effects of a substanceusedisorderonindividualswithmooddisorders—particularlyBD.Alcoholandsubstanceusedisordersarelinkedtohighratesoftreatmentnon-adherence (i.e., not following a treatment plan including nottakingmedicationsasprescribed)andtolowerratesofrecovery,greaterriskofaggressionandviolence,ahigherrateofattemptedandcompletedsuicide,andalessfavourableresponsetoconven-tionaltreatments(Brady&Sonne,1995;Strakowski,1995).

Substanceusedisordersmayinvolveanynumberofsubstances—such as nicotine, alcohol, cannabis, cocaine, heroin, amphet-amines,MDMA,PCPandothers.Howfrequentlythedifferentsubstancesareusedcandiffergreatly,ascantheriskofbecomingdependent.Giventhedifferentwaysthesesubstanceswork,andthevariouseffectstheyhave,itisimportanttolookforspecificprofilesofsubstanceuseindifferentmooddisorders.Althougharecent study has suggested that those experiencing mania orhypomania are at increased risk of a substance use disorderinvolvinganysubstancebutthoseexperiencingdepressionareatincreased risk for a substance use disorder involving sedativesonly(Merikangasetal.,2007),therereallyisnoclearpatternofspecific drugs being associated with particular mood disorders.Furtherresearchmayhelptodeterminewhetherornotsubstancesarebeingusedindiscriminatelybythosewithmooddisordersoriflinkagesbetweencertaindrugsandmooddisordersexist.


Thepossiblecausesofconcurrentmoodandsubstanceusedisordersaremany,buttwotheoriesreceivethemostattention:overlapping predisposition and disorder inducing disorder. An overlapping pre-disposition(asdiscussedinChapter 3)encompassestheideaofacommon vulnerability to both conditions —something about apersonthatmakeshimorherpronetoboth.Thiscouldbeduetoageneticpredisposition(i.e.,beingbornwithgenesthatmakeboth disorders likely), or common environmental factors thatinfluencebothdisorders.Thetheoryofdisorderinducingdisorderpostulatesthatonedisorderactuallycausestheother.Withthis


m o o d d i S o r d e r Sm o o d d i S o r d e r S a n d S u b S ta n c e u S e d i S o r d e r S a n d S u b S ta n c e u S e d i S o r d e r S

theory,eithermooddisorderswouldinducesubstanceusedisorders,or substance use disorders would induce mood disorders— orperhapsbothcouldbepossible.

Researchinvolvingfamily,adoption,andtwinstudieshasshownthatgeneticfactorsdoplayaclearroleinmooddisorders.Studiesthat compare identical (monozygotic) and fraternal (dizygotic)twins can help to determine the role of inherited genes in thedevelopmentofsubstanceuseandmooddisorders;thisconceptisreferredtoasthe heritabilityofacondition.TheheritabilityofMDD varies greatly in the research—between 20 and 80%—which is likelydue todifferences inhowthe studieswerecon-ducted.However,arecentreviewofmanystudiesconcludedthattheheritabilityofMDDisbetween31and42%.Whenitcomesto BD, the heritability appears to be higher, at around 71%(Edvardsen et al., 2008). As for heritability and substance usedisorders, the research findings are consistent and support themajorroleofgeneticsinsubstanceusedisorders(Agarwaletal., 2008).Anoverlappinggeneticpredispositionmayincreasetheriskofconcurrentsubstanceuseandmooddisorders;however,giventhedifficultyofidentifyingspecificgenesforpsychiatricdisorders(Goldman,2005;Li&Burmeister,2009),nospecificgenesmakingpeoplevulnerabletobothconditionshaveyetbeenidentified.

A number of environmental factors have also been associatedwith increased risk forbothmoodand substanceusedisorders(i.e.,familydisruption,poorparentalmonitoring,andlowsocialclassofrearing),supportingthenotionofanoverlappingenvi-ronmentalpredispositiontothesedisorders(Kendleretal.,2003).Recently,childhoodtraumahasreceivedattentionasariskfactorfor post-traumatic stress disorder—but early childhood traumaseemsjustaslikelytoleadtosubstanceuseandmooddisorders(Kilpatrick,2003).Similarly,lowbirthweightseemstoincreaserisk for psychiatric disorders including substance use disordersandmooddisorders.

Thetheorythatonedisordermaycausetheotherlendsitselftothe ideaof self-medication (alsodiscussed inChapter3),where

peopleattempttotreattheirmooddisorderwithdrugsoralcohol(Khantzian, 1985). Studies attempting to provide evidence forthis have not been very successful. For example, research hasshown that substance use disorders often begin before mooddisorders.Still,clinicalexperienceindicatesthatitispossibletoidentifypatientswhodevelopsubstanceusedisorderswithinthecontext of their mood disorders. Some research has suggestedthatthismaybeparticularlytrueforthosewithmanic,hypomanicormixedstates(Marikangasetal., 2008;Marimmanietal.,2006).By contrast, mood disorders caused by substance use disordersarerecognizedinthattheyexistasaseparatediagnosticentityintheDiagnostic and Statistical Manual of Mental Disorders (DSMIV).Itis,however,adiagnosisrarelyusedbyclinicians.

Overall, some evidence can be found for each of the possiblemechanismsthatmayleadtoconcurrentsubstanceuseandmooddisorders, but none has been shown to explain the majority ofcases.Partofthedifficultyinexplaininghowsubstanceuseandmood disorders occur together is that the boundaries betweendifferentmooddisordersandthevarietyofmooddisorderswithinanygivencategorymakesresearchinthisareaquiteachallenge.Theonsetofamoodorsubstanceusedisorderisalsodifficulttodefine.Todeterminetheexacttimingandthereforethesequenceofthetwodisordersinanindividualislessthanstraightforward.

Althoughwecurrentlylackathoroughunderstandingofthefactorsthatcauseconcurrentmoodandsubstanceusedisorders,betteranimalmodelsandnewmethodsofassessinghumanbrainactivityhaveledtomajorimprovementsinourunderstandingofthebrainmechanisms involved in these disorders (Paterson & Markou,2007;Quelloetal.,2005).Brainmechanismsarestudiedatdif-ferentlevels;atthegross-anatomicalorstructurallevel(regions,areasandnetworksinthebrain),regionalnetworksofthebraininvolvedinlearningplayaroleinbothmoodandsubstanceusedisorders.Theseincludetheamydala-hippocampus-cingulate net-work(LaBar&Cabeza,2006).Changesinotherpathwaysmayalsohavearole.Newtechnologiesthatdirectlymeasureactivityinspecificbrainregionsandnetworksallowforabetterappreciation


oftheroleofbrainstructuresandsystemsandhelpimproveourunderstandingofdiseaseprocesses (seeFigure4).At the inter-cellularlevel(howspecifickindsofcellsinteractinthebrain,e.g.,vianeuro transmitters)—wheremedicationsoftenact—dopamine,achemicalinthebrain,hasbeenstudiedheavilyinthecontextofsubstanceabuseanddependence.Othertransmittersystemssuchastheserotonergicsystemandthenorardrenergicsystemarealsoof interest in both substance use and mood disorders. At theintracellularormolecular level (i.e., activitywithin cells in thebrain)theprocessesareprobablytheleastunderstoodsofar,butnew knowledge from research is developing at a rapid pace.However,sincesomemedicationsusedtotreatBDworkatthislevel, BDresearchhasrecentlyfocusedatthe intracellular level(Bezchlibnyk&Young,2002;Martinowitchetal.,2009)Thesemedicationssometimesworkforsubstanceusedisordersaswell—indicatingapossiblecommonintracellularpathway.

So-called biomarkers should also be examined. Biomarkers aresubstancesthat,whenfoundinthebody,indicateacertaindiseaseispresent.Whentheyareavailable,biomarkerscanmakediag-nosingaparticular illnessmorestraightforward.Theoverlapofmoodand substanceusedisorders complicates the search for abiomarkerforeachdisorder.Tobeuseful,biomarkersspecificforadisordersuchasMDDshouldnotbealteredbyasubstanceusedisordersuchasalcoholuse.However,atthispointnearlyhalfofthepotentialmarkersforMDDarealsoalteredbysubstanceuse(Mössneretal.,2007).Giventheoverlapofmoodandsubstanceuse disorders, markers for concurrent disorders may be worthconsidering.Thesemighthelprefinethediagnosisandtreatmentfortheseconcurrentdisorders.

Giventhesignificantoverlapinmechanismsleadingtosubstanceuseandmooddisordersaswellastheimpactofconcurrentsub-stanceuseandmooddisordersonclinicalcourseandoutcome,theimportanceoftreatingbothconditionsinanaffectedindividualisobvious.However,ourcurrenthealthcaresystemisstrugglingtomeetthisneedandprovidethebestpossiblecare.Becausemooddisordersareconsideredmentalhealthconditionsbesttreatedby

psychiatristsandmentalhealthprofessionals,andsubstanceusedisordersareoftennotseenasmentalhealthconditionsandassuchareusuallytreatedbyaddictionspecialists,anumberofchal-lenges for patients with both conditions and for the treatmentsystemexist.Forexample,apatientmaynotbeacceptedfortreat-mentofonedisorderbecausethespecialisttreatmentcentredoesnotsupportpatientswiththeotherdisorder.Researchalsotendstofocusonpatientswithonespecificdisorder—meaningpatientswithconcurrentdisordersarenotrepresentedinmostfindings.

Thisproblemhasrecentlyreceivedincreasingattention,andtheneedtoimprovetreatmentavailabilityforpatientswithconcurrentdisorders is becoming better appreciated.To improve care andtreatmentforsuchpatients,changestothetreatmentsystemarerequired,including:•Improveddetectionanddiagnosisoftheconcurrentdisorder•Increasedawarenessandacceptanceoftheneedtotreatboth

disordersconcurrently•Increasedfocusonthedevelopmentoftreatmentsfor

concurrentdisorders•Increasedavailabilityoftreatmentoptionsforthesepatients

Toimprovedetection,diagnosisandtreatmentofaseconddisorderin patients already diagnosed with a first disorder, treatmentproviders need to be aware of concurrent disorders (i.e., buildtheirprofessionalknowledge).Treatmentprovidersalsoneedtoappreciatetheimportanceoftheseconddisorderandbeawareofavailabletreatmentoptions(amatterofprofessionalattitudeandovercomingstigma).Onesimplewaytoavoidmissingaconcurrentdisorder is to make sure the right assessment instruments areavailable.Givenprofessionals’almostuniversallackoftime,self-assessmentinstrumentsmaybeafeasibleoption.Uptonow,onemethodofdealingwithconcurrentdisordershasbeen todeferthetreatmentoftheseconddisorderuntilafterthefirsthassuf-ficientlyimproved.Yetitisconsideredgoodpracticetotreatbothdisordersatthesametime.Thatsaid,withtreatmentprovidersnormally having the expertise to treat one disorder but notnecessarilytheother,simultaneouslytreatingbothcanposeabig

Substance Abuse in Canada: Concurrent Disorders 43

g e n e n e t wo r k s

e n v i ro n m e n t

b e H av i o u r

d e p r e s s i o n

a d d i c t i o n

F i g u r e 4

ov e r l a p p i n g g e n e - e n v i ro n m e n ta l

Fac to r s m ay b e r e s p o n s i b l e F o r t H e

c o m o r b i d i t y o F s u b s ta n c e u s e a n d

m o o d d i s o r d e r

Inhibitory Control

Motivation Drive

Reward

Memory Learning

m o o d d i s o r d e r s a n d s u b s ta n c e u s e d i s o r d e r s

F i g u r e 4

Shows how genes, the environment and brain function interact, and how that interaction likely contributes to the behaviour changes that occur in substance abuse and in depression. Overlapping environmental, genetic or biological factors in the brain could account for the high degree of co-occurence between substance abuse and depression (Volkow, 2004).

l e g e n d(ACG) anterior cingulate gyrus

(AMG) amygdala

(Hipp) hippocampus

(NAC) nucleus accumbens

(OFC) orbitofrontal cortex

(PFC) prefrontal cortex

(SCC) subcallosal cortex

(VP) ventral pallidum


challenge.Thereisaneednotonlytopromotegoodpracticebutalsototrainprofessionalswhoareinapositiontogivetreatmentfor both mood and substance use disorders— at the same levelofexpertise.

Thedevelopmentofnewtreatmentshastendedtofocusonsingledisorders,resultinginanowurgentneedtoadvancethetreatmentoptions forconcurrentdisorders.Forexample,whenthemoodstabilizerValproate isusedtotreatpatientswithBD,it seems toalso decrease heavy drinking when there is concurrent alcoholdependence(Salloumetal.,2005).Buprenorphin,amedicationforsubstanceuse,hasbeenshowntopossiblyimprovethemoodof patientswith a substanceusedisorderwho alsohave MDD(Bodkin et al., 1995). Lithium, when used to treat adolescentswith BD, has been shown to also be effective in treating theirconcurrentsubstanceusedisorder(Freye&Salloum,1998).Butmorestudiesonthetreatmentofconcurrentdisordersareneeded(Kosten & Kosten, 2004). To date, a very limited number ofstudieshavebeenconductedforspecificconcurrentdisorders.

Inadditiontothedevelopmentofmedications,counsellingandpsychotherapyspecifictopatientswithconcurrentdisordersareimportant(Carroll,2004).Thecombinationofmedicationandtalk therapy for concurrent mood and substance use disordersneeds to be further developed and tested, then put into useoutsideoftheresearchenvironment(Weissetal.,2004).Finally,theeffectofspecificnon-medication-basedtreatmentsformooddisorders (like ECT, for example) on substance use disordersneedstobestudied.

•• Mood disorders constitute the single largest group of Mood disorders constitute the single largest group of psychiatric disorders and include Major Depressive Disorder, psychiatric disorders and include Major Depressive Disorder, Bipolar Disorder, Dysthymia and Cyclothymia.Bipolar Disorder, Dysthymia and Cyclothymia.

•• People with mood disorders are more likely to use People with mood disorders are more likely to use substancessubstances——and people using substances are also more and people using substances are also more likely to suffer from mood disorders.likely to suffer from mood disorders.

•• Substance use is highest in those with Bipolar Disorder, Substance use is highest in those with Bipolar Disorder, but the risk of a substance use disorder is still at least but the risk of a substance use disorder is still at least double for those with Major Depressive Disorder.double for those with Major Depressive Disorder.

•• In general, substance dependence has been shown to be In general, substance dependence has been shown to be linked with mood disorders to a greater degree than either linked with mood disorders to a greater degree than either substance abuse or substance use.substance abuse or substance use.

•• Having both a substance use disorder and a mood Having both a substance use disorder and a mood disorder affects the clinical course of both disorders (treatdisorder affects the clinical course of both disorders (treat--ment engagement, thoughts of suicide, homelessness, ment engagement, thoughts of suicide, homelessness, increased risk of victimization) and their clinical outcomes increased risk of victimization) and their clinical outcomes (life expectancy, suicide, treatment outcome).(life expectancy, suicide, treatment outcome).

•• Mechanisms that might explain the overlap of substance Mechanisms that might explain the overlap of substance use and mood disorders are an use and mood disorders are an overlapping predispositionoverlapping predisposition (a common vulnerability involving genetic and/or environ(a common vulnerability involving genetic and/or environ--mental factors) and mental factors) and disorder inducing disorderdisorder inducing disorder (where one (where one disorder causes the other). disorder causes the other).

•• To improve care and treatment for people with concurrent To improve care and treatment for people with concurrent substance use and mood disorders, changes to the current substance use and mood disorders, changes to the current treatment system are required, including: treatment system are required, including: •• Improved detection and diagnosis of concurrent disorders Improved detection and diagnosis of concurrent disorders •• Increased awareness and acceptance of the need to Increased awareness and acceptance of the need to

treat both disorders at the same timetreat both disorders at the same time•• Increased focus on the development of treatments Increased focus on the development of treatments

for concurrent disordersfor concurrent disorders•• Increased availability of treatment options for Increased availability of treatment options for

these patientsthese patients




Increasingtheavailabilityofspecifictreatmentoptionsrequiresestablishingnewprogramswithinthecurrenttreatmentsystem.Thisneedhasrecentlybecomebetterappreciatedforindividualswithbothschizophreniaandsubstanceusedisorders.However,suchprogramsneedtobeexpandedtoreachpatientswithotherconcurrentdisorderssuchasmoodandsubstanceusedisorders —asignificantlylargergroup.

c o n c l u S i o n S a n d i m p l i c at i o n S f o r c a n a d i a n S

Thesignificantoverlapbetweenmoodandsubstanceusedisordersis evident. Clearly, there are a number of gaps in our currentknowledge of concurrent mood and substance use disorders;unfortunately,thelevelofongoingresearchintoconcurrentdis-ordersdoesnotmatchthepublichealthimpactofsuchdisorders.Evenso,advancementsinthefieldarebeingmadeandsignificantimprovementsinthemanagementandtreatmentofpeoplewiththesedisordersisstillpossiblebasedonwhatweknownow.Theco-occurrenceofsubstanceuseandmooddisordersneedstobeacentral issue in their effective treatment, and our health caresystemmustadapttomeettheuniquechallengestheypose.


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PsychosisPsychosisand substance use and substance use disordersdisorders

tony p. george, md, frcpc CAMHanduniversityoftoronto

diana blank, md universityoftoronto

tony p. george, md, frcpc

Dr.tonyGeorge,MD,FrCPCDr.tonyGeorge,MD,FrCPCisProfessorofPsychiatry,isProfessorofPsychiatry,PsychologyandMedicalPsychologyandMedicalSciences,andtheChairinSciences,andtheChairinAddictionPsychiatryattheAddictionPsychiatryattheuniversityoftoronto,anduniversityoftoronto,andClinicalDirectoroftheClinicalDirectoroftheSchizophreniaProgramatSchizophreniaProgramattheCentreforAddictionandtheCentreforAddictionandMentalHealthintoronto,MentalHealthintoronto,on,Canada.on,Canada.

diana blank, md

Dr.DianaBlank,MDisaDr.DianaBlank,MDisaPG-4residentinPsychiatryPG-4residentinPsychiatryattheuniversityoftoronto,attheuniversityoftoronto,toronto,on,Canada.toronto,on,Canada.


acknowledgementsthisworkwassupportedinpartbygrantsK02-DA-16611,r01-DA-13672,r01-DA-14039andr01-DA-15757fromthenationalInstituteonDrugAbuse(nIDA),anIndependentInvestigatorAwardfromthenationalAllianceforresearchonSchizophreniaandDepression(nArSAD),theCanadaFoundationforInnovation(CFI),theCanadianInstitutesonHealthresearch(CIHr)andtheendowedChairinAddictionPsychiatryfromtheuniversityoftoronto.


66

i S S u ei S S u e

Psychoticdisordersareasetofseverementaldisordersinwhichcontact with reality is highly distorted for those affected.Thismakesitdifficultforapersonwithpsychosistofunctioninday-to-daylife.Themostcommonformofpsychosisisschizophrenia,affectingbetween1to1.5%ofthepopulationworldwide(Freedman,2003).Thosewith schizophrenia typicallyexperiencedelusions,hallucinationsanddisorganizedthinking—knowncollectivelyaspositive symptoms,aswellaslackofmotivation,withdrawalandsocialisolation—togetherknownasnegative symptoms.Theyalsoexperienceproblemswithmemory,attentionanddecisionmaking;thesearecalledcognitive deficits.

Studieshaveshownthatpriortotheonsetofanactualpsychoticphase of schizophrenia, changes occur in thebrain (Pantelis etal.,2003).Thismayexplainthesymptomsoftenseenbeforetheillnessdevelops(thepre-illnessorprodromalphaseofthedisorder).During the early phase, subtle or mild psychotic symptomstogetherwithothermanifestationssuchasreducedconcentrationand attention, social withdrawal, anxiety, depression and sleepdisturbancemayoccur(Yung&McGorry,1996).Variousdegreesofsocialdysfunctionmayalsobepresent.Thepre-illnessorpro-dromephasecanstartasearlyasfiveorsixyearsbeforethefirst

psychotic episode (Klosterkotter et al., 2001) andusuallyhas aslow onset.The symptoms during this phase typically includethingsother thanpsychosis and they tend towaxandwane inseverity. Following the onset of these symptoms come unusualbehavioursandvaguepsychoticsymptomsthatgraduallyincreaseandworsen.Oftenthesymptomsarenotnoticedbyothersuntiltheybecomemoreintenseandleadtosomedegreeofsocialdys-function(Yung&McGorry,1996;Heinrichs&Carpenter,1985).Not everyone who experiences prodromal psychotic symptomswilldevelopfull-blownpsychosis;however,theseearlysymptomstogetherwithotherriskfactors—includingsubstanceuse(Yung,2007)—willincreasetheriskforfuturepsychoticillness.

Substanceusedisorders,muchlikepsychoticdisorders,arechronic,relapsingillnesses.Studieshaveshownthatupto50%ofpeoplewithsubstanceusedisordershaveaco-occurringpsychiatricillness(Regieretal.,1990),andsubstanceusedisordersareparticularlyprevalentinthosewithpsychoticdisorderssuchasschizophrenia(Selzer&Lieberman,1993).Infact,amongstpatientswithpsychoticdisorders,theriskofhavingasubstanceusedisorderistwo-tofour-fold higher than in the general population (Regier et al.,1990;George&Krystal,2000;Ziedonisetal.,2005).

derek Derek,a17-year-oldwhohasrecentlyquitschool,isafraidthathisfrequentcannabisusewill“fryhisbrain”.Hehastriedtoquitonnumerousoccasionsbuthasbeenunsuccessful.Hefirsttriedcannabisattheageofeight,whenhefoundsomeleft-overjointsafterhissisterhadaparty.ByGrade8,Derekwassmokingcannabisdailyandnowisupto25“poppers”eachday.Ayearagohewashospitalizedwithpsychosisduringaperiodofheavycannabisuse.He’scurrentlyonanantipsychoticmedicationbutcontinuestoexperiencesomepsychoticsymptoms.Itwashis

paranoia,infact,thatledhimtoquitschool.Henowspendshisdaysinhisparents’basementapartment,smokingcannabisandwatchingmovies.Hefrequentlyfantasizesaboutendinghislifeandmostrecentlyhasdevelopedsymptomsofdepressionthataddtohishopelessnessandlackofself-esteem.Derekwondersifthereisanywayoutofhissituation.


Anumberoffactorsappeartoleadtoco-occurringsubstanceusedisorders andpsychosis—withboth genetic and environmentalfactorsplayingarole.Incasesoffirst-episodepsychosis,themisuseof alcohol and illicit substances may produce a transient, self-limited psychosis or it may lead to a more enduring psychosis(laterdiagnosedasschizophrenia).Ifschizophreniaisthediagnosis,it might have been triggered by the drug use (e.g., cannabissmoking)butwas likelyalsopromotedbyindividualbiologicalriskfactors(e.g.,geneticvulnerabilitytopsychosis).

Tocomplicatethepicturefurther,substanceusemakesdiagnosingthetypeofpsychoticdisordermoredifficult.Forexample,studieshaveshownthatover50%ofadolescentpatientsseeninpsychiatricclinicsuse substances (Green et al.,2007).Thisunderlines theimportanceofclarifyingwhetherasubstanceistoblameforanypsychoticsymptoms,orwhethertheuseofsubstancesmayhavetriggered a functional psychotic illness such as schizophrenia(Boutros&Bowers,1996).However,itisoftennotpossibleintheinitialpresentationtodistinguishbetweenthetwo.Thehistoryofsubstanceuse, thetypesofdrugsmisused(useofmorethanonesubstanceiscommon),andtherelationshiptotheonsetofpsychosis can help to determine the type of psychosis. Factorsassociatedwithperiodsofdrugabstinenceorreduction,aswell

ascircumstancesfordrugandalcoholrelapsearealsoimportant.Incasesofdrug-inducedpsychosis,itmaytakeseveralweeksorevenmonths for thepsychotic symptoms to fully resolve — andthecourseof recoveryvariesgreatly.Early treatmentwithanti-psychoticdrugsiscrucialtominimizetheimpactofpsychosisonbrainfunction.Infact, it iswell-knownthatearly interventionin prodromal and first-episode psychosis improves long-termfunctional outcomes in these patients (Ricciardi, McAllister &Dazzan,2008).

Tobacco and cannabis are the most used substances by peoplewithpsychoticdisorders.Theprevalenceofcigarettesmokingistwo-tothree-foldhigherinpatientswithschizophrenia(58–88%)comparedtothatinthegeneralpopulation(Kalman,Morrisette&George,2005;Morisano,Bacher,Audrain-McGovern&George,2009). The rate of quitting smoking is much lower than thegeneralpopulationandvariesgreatlybydisorder.Thequitrateinthosewithoutasubstanceuseorpsychiatricconditionis42.5% —comparedtoonly16.9%inthosewithanalcoholdisorder,26%inthosewithbipolardisorder,26%inthosewithdepressionand0%inpersonswithpsychosissuchasschizophrenia(Lasseretal.,2000).Cigarettesmokingappearstoreducethesideeffectsofanti-psychoticdrugs(e.g.,stiffness),andmayhelpwithvariousaspectsof cognitive dysfunction (working memory, attention, sensorygating)thatareassociatedwithschizophrenia(George,2007;Sacco,Bannon&George,2004).Littleevidenceexists,however,thatshowstobacco use worsens symptoms or the course of schizophrenia(Sacco,Bannon&George,2004).

Aftertobacco,cannabisisthemostusedsubstancebythosewithco-occurringpsychoticdisorders.Severalstudieshaveexaminedtheroleofcannabisinactuallytriggeringpsychosisandschizo-phrenia.Infact,astudyfromSwedenthatfollowedpeoplefor15 yearsfoundthattheriskofschizophreniawassixtimeshigherinhighusersofcannabis(thosewhousedcannabisonmorethan50occasions)thaninnon-users.Evenwhenotherfactorssuchassocialbackgroundandpreviouspsychiatricillnessweretakenintoaccount,thelinkbetweenheavycannabisuseandschizophrenia


p S y c h o S i Sp S y c h o S i S a n d S u b S ta n c e u S e d i S o r d e r S a n d S u b S ta n c e u S e d i S o r d e r S

remained.Thissuggeststhatcannabisisindeedanindependentriskfactorfordevelopingschizophrenia.Afurtheranalysisofthesamestudypopulation27yearslater(Konings,Henquet,Maharajah,Hutchinson &Van Os, 2008) continued to show a significantrisk for schizophrenia—the more cannabis that was used, thehighertherisk.Theresearchersofthisstudyestimatedthat13%ofschizophreniacasescouldactuallybeaverted ifcannabisusecouldbestopped(Zammitetal.,2002).

Since then, several other studies have supported these findingsand have even expanded on the results of the Swedish study.Additionalfindingsinclude:

•Cannabisusedecreasestheageofonsetoffirstpsychoticepisode(Gonzalez-Pintoetal.,2008).

•Youngadolescentsaremorevulnerabletotheeffectsofcanna- bisandathigherriskfordevelopingschizophrenia,whichsuggeststhatcannabismaybemoreharmfulduringthecriticalbraindevelopmentalperiods(Koningsetal.,2008).

•Continuingtousecannabisafterbeingdiagnosedwithschizophreniaorwhenhavingpsychoticsymptomsmaycauseearlierormorefrequentrelapsesandhospitalizations,andaggravatesomesymptoms.

•Ageneticvariationinsomepeoplethatleadstolowerlevelsofdopamine(abrainchemical)incertainareasofthebrainhasbeenfoundtobelinkedwiththediagnosisofearlypsychosisinthosewhousedcannabisasadolescents.Thissuggeststhat,geneticallyspeaking,somepeoplemaybemorevulnerabletothenegativeeffectsofcannabisandatgreaterriskfordevelop-ingschizophrenia(Caspietal., 2005).

•Levelsofanotherbrainchemicalcalledneurotrophinswerehigherinschizophreniapatientswhousedcannabisformorethantwoyearsthanineitherpeoplewithschizophreniawhodidn’tusecannabisandinhealthysubjects.Thisindicatesthatit’spossiblethatcannabisuseinvulnerablepeoplemayleadtobraincelldamage(Jockers-Scherubletal.,2004).Regularconsumptionbythesepeoplecouldhastentheonsetofschizophrenia.

•IfpeoplewithschizophreniaareadministeredTHC(theactiveingredientincannabis),itcantemporarilyincreasepositiveandnegativesymptomsofschizophrenia,andfurtherimpaircognitivefunction(D’Souzaetal.,2005).

Considered together, these findings suggest that biological riskfactorsmaymakesomepeoplewhoarepronetopsychosismorevulnerabletotheeffectsofcannabis.Inaddition,cannabisappearstoworsenthesymptomsandthecourseofpsychoticdisorders.

Ifalcoholisinvolved,patientswithpsychoticdisordersmoretypi-callyhaveadiagnosisofalcoholabuseratherthandependence,andtendtoengagein“binge”drinkinginsteadofregularalcoholuse.Reasonsforthisparticularpatternofalcoholconsumptionarenot clear,but itmay involve anotherbrain chemical calledglutamate;bothschizophreniaandalcoholarelinkedtochangesinthebrainrelatedtoglutamate(Heilig&Egli,2006).Ofinterest,when people with chronic alcoholism abstain from drinking,theycanexperienceanalcoholic“hallucinosis”inwhichtheyhaveauditoryandvisualhallucinationsandparanoidideation — com-monpsychoticsymptoms.

Theuseofstimulants(includingsubstancessuchascocaineandmethamphetamine)ishighlyprevalentinpersonswithpsychoticdisorders. Heavy stimulant use appears to increase the risk ofpsychotic symptomspossibly throughaprocessknownasdrug sensitization. In patients with schizophrenia, stimulant misuseleads to a worsening of positive symptoms of psychosis (e.g.,delusions, hallucinations, thought disorder), but interestinglyenough,thenegativesymptomsofpsychoticillness(lackofmoti-vationormeaningfulsocialrelationships)appeartobelowerinthosewithpsychosiswhousestimulants(Talamoetal.,2006).

TheclassofdrugsthatincludesPCP(phencyclidine)andketamineis known to produce psychotic symptoms that mimic all theclinicalfeaturesofschizophrenia—positive,negativeandcognitivesymptoms.Infact,ketamineadministrationhasbeenshowntoreplicate the symptoms of schizophrenia in healthy volunteers


(Krystaletal.,1994),andworsenpositive,negativeandcognitivesymptomsinpatientswithschizophrenia(Malhotraetal.,1997).The action site of these drugs—receptors in the brain for thechemical glutamate—hasalsobeenimplicatedinschizophrenia,suggestingacommonneurobiologicalmechanism.

Substancemisuseisassociatedwithanearlieronsetofpsychosis,greater resistance to treatments thatarenormallyeffective, andhigherratesofemergencyroomvisitsandpsychiatrichospitalization(Ziedonisetal.,2005).However,wehavefeweffectivetreatmentsfor co-occurring psychotic and substance use disorders—andperhapsmoreprofoundly,ourtreatmentsystemslackthecapacitytomanagethesehighlycomplexpatients.


Muchlikewithanxietydisorders(Chapter3)andmooddisorders(Chapter5),therearetwocommonlyusedtheoriestoexplaincon-currentpsychoticandsubstanceusedisorders:theself-medicationhypothesisandanaddiction vulnerabilityhypothesis(Chambers,Krystal&Self,2001).

Theself-medicationhypothesissuggeststhatpatientswithschizo-phreniausedrugstoreducetheirsymptomsorthesideeffectsoftheirmedication.Thiswouldinferthattheirsubstanceuse isaconsequenceoftheirschizophreniasymptomsand/oritstreatment.Thishypothesislacksevidencefromresearchtosupportit,andassuchremainscontroversial(Khantzian,1997).

Theaddictionvulnerabilityhypothesis suggests that theriskofschizophreniaorpsychosisishigherinthosewhousedrugsthanthosewhodon’tbecausethetwodisorderssharegenesorbrainabnormalities.Theseindividualsarevulnerabletobothpsychosisandsubstanceuse.Thishypothesis looksatbothsubstanceuseandschizophreniaasdistinctdisorderswithasharedbasisinthebrain—specifically, the brain’s dopamine systems (Chambers etal.,2001).Unlike the self-medicationhypothesis, this theory issupportedbyexperimentalevidence(George,2007).

Indeed,evidenceofneurobiologicalmechanisms—relatingtothestructureandfunctionofthebrain—helpsexplaintheco-occur-rence of psychosis and substance use disorders. Systems in thebraininvolvingthebrainchemicaldopaminearethoughttobeinvolvedindruguse,andmayalsoplayaroleintherelationshipbetween addictions and psychotic disorders (Green, 2006). Inschizophrenia, some parts of the dopamine systems work toomuch(hyperfunction)whileothersworklessthannormal(hypo-function)(Georgeetal.,2000;Georgeetal.,1995).Theresultingimbalanceintheleveloffunctioningisthoughttoleadtoincreasedsusceptibility of a person with schizophrenia to substance usedisorders—independentoftheschizophreniaitself(Yung,2007).Other dysfunction within the dopamine systems is thought toincreasevulnerabilitytobothsubstanceusedisordersandpsychosis(Sacco,Bannon&George,2004;Swanson,VanDorn&Swartz,2007). For example, some evidence suggests that nicotine mayactually improve the cognitive problems and dopamine systemabnormalitiesinthebrainsofpeoplewithpsychosis(George,2007).

Inlightoftheco-occurrenceofsubstanceuseandpsychoticdis-ordersandthepossiblesharedbasisforthesedisorders,treatmentoptionsmustbecarefullyconsidered.

pharmacological approaches:Whentreatingpsychosiswithmedi-cations,itiscriticalthateveninthepresenceofactivesubstanceusethepsychoticsymptomsbeeffectivelymanagedandtreated—evenifthepsychosisisdrug-induced.Methodsofdrugdeliverythat help to ensure the medication is actually being taken arecrucial;theseincludetheuseofonce-dailydosingregimensandthe employment of long-acting, injectable antipsychotic drugs(called depot medications) (Green, 2006). Evidence shows thatso-called second generation antipsychotic drugs (these includeclozapine, olanzapine, and quetiapine) may reduce drug andalcohol craving and misuse (Green, 2006; George et al., 1995;Swansonetal.,2007;Smelsonetal., 2006).Medicationsusedtotreataddictionsmaybeeffectiveforthetreatmentofco-occurringsubstanceusedisorders in thosewith schizophrenia (George etal.,2008;Petrakisetal.,2004).



Neurobiology of Psychosis Neurobiology of Psychosis

Symptoms of Psychosis Symptoms of PsychosisSubstance Abuse Vulnerability Substance Abuse Vulnerability

S e l f - m e d i c at i o n h y p ot h e S i S

(negative reinforcement model)(negative reinforcement model)p r i m a ry a d d i c t i o n h y p ot h e S i S

(positive reinforcement model)(positive reinforcement model)


t wo m o d e l S to e x p l a i n c o - o c c u r r i n g p S yc h ot i c t wo m o d e l S to e x p l a i n c o - o c c u r r i n g p S yc h ot i c

a n d S u b S ta n c e u S e d i S o r d e r Sa n d S u b S ta n c e u S e d i S o r d e r S

behavioural approaches:Theuseofbehaviouraltherapies—andinparticularmotivationalinterviewingandcognitive-behaviouraltherapies—is a necessary component for treating co-occurringpsychotic and substance use disorders (Ziedonis et al., 2005).Thesetherapiescanalsobeusedtohelpensurethatpatientstaketheirmedications asprescribed—called adherence to treatment.Ideally,suchtreatmentshouldtakeplacewithinagroupformat,sincethisismorelikelytoassistwithdeficitsinsocialskillsandassertivenesscommonlyseeninthosewithschizophreniaandotherpsychoticdisorders.

integrated “dual recovery” approaches:Ideally,bothpharmaco-logicalandbehaviouraltreatmentsarecombinedforthetreatmentof co-occurring substanceuse andpsychoticdisorders.Clinicalstaffshouldbetrainedinbothinitiationofabstinencefromdrugsandalcoholandinpsychosisandcrisisstabilization.Unfortunately,thisisoftennotthecasewithproviders.

Once substance use and psychotic symptoms are stabilized, anapproachthataddressessimultaneousrecoveryfrombothdisordersispreferred.Usingmodifiedcognitive-behavioural (relapse-pre-vention)approachesforthesubstanceuseandpsychosisintegratedinto a single treatmentprogram is ideal (Ziedonis et al.,2005;Weissetal.,2007).

Giventhecomplexitiesoftreatingclientswithco-occurringpsy-chosis and substance use disorders, the ideal delivery of thesetreatmentservicesisatasinglecentrewhereprovidersaretrainedinbothmentalhealthandaddictionsassessmentandinterventions(Drake, Mercer-McFadden, Mueser, McHugo & Bond, 1998).This service model (presented in Figure 6) is a version of thequadrant model(Ziedonisetal.,2005;Drakeetal., 1998),whichproposesthatclientswiththehighestmentalhealth(psychosis)andaddictionseverityshouldreceiveservicesinahighlyspecial-izedtreatmentsetting,albeitinatime-limitedmanner(Minkoff,Zweben,Rosenthal&Ries,2003).Naturally,giventhehighcostsofsuchspecializedservices,thegoalwouldbeforrapidstabilizationofsymptomsandaquickreturntomoreroutinelevelsofcare.Forexample,aftersuchacutestabilizationandspecializedtreat-ment,clientswhohaveaprimarypsychoticdisorder(e.g.,chronicschizophrenia) would then return to a primary mental healthtreatmentsettingwhereadualrecoveryapproachcanbefollowed.Thoseclientswithaprimary substanceusedisorder (e.g.,drug-inducedpsychosis)wouldreturntoanaddictionstreatmentsetting.Ultimately,oncethepatientwithcomplexconcurrentpsychoticand substance use disorders has achieved long-term psychoticdisorderandaddictiveillnessstability,thatindividualwouldbeplacedincommunitytreatment,ideallyataprimarycare-orientedmedicalcentre.

Adapted from: Chambers, R. A. et al. (2001)


high mental health / low addictionS SeVerity

(Mental Health Treatment Setting)high mental health / high addictionS SeVerity

(Specialized Concurrent Disorders Treatment Facility)

low mental health / high addictionS SeVerity

(Addictions Treatment Setting)low mental health / low addictionS SeVerity

(Community Treatment)


Q ua d r a n t m o d e l f o r t r e at m e n t Q ua d r a n t m o d e l f o r t r e at m e n t

o f c l i e n t S w i t h c o m o r b i d a d d i c t i o n S o f c l i e n t S w i t h c o m o r b i d a d d i c t i o n S

a n d p S yc h ot i c d i S o r d e r Sa n d p S yc h ot i c d i S o r d e r S

Addictions Severity

Men

tal H

ealth

Sev

erit

y


thisquadrantmodelproposesthatclientswiththehighestthisquadrantmodelproposesthatclientswiththehighestmentalhealth(psychosis)andaddictionseverityshouldmentalhealth(psychosis)andaddictionseverityshouldreceiveservicesinahighlyspecializedconcurrentdisordersreceiveservicesinahighlyspecializedconcurrentdisorderstreatmentsetting,albeitinatime-limitedmanner.Wheneithertreatmentsetting,albeitinatime-limitedmanner.Wheneithermentalhealthoraddictionseveritydiminishes,thepatientmentalhealthoraddictionseveritydiminishes,thepatientcanbetransitionedtospecializedaddictionormentalhealthcanbetransitionedtospecializedaddictionormentalhealthtreatmentsetting.eventuallywhenbothmentalhealthandtreatmentsetting.eventuallywhenbothmentalhealthandaddictionseverityarelow,acommunitytreatmentsettingaddictionseverityarelow,acommunitytreatmentsettingwouldbeappropriate.wouldbeappropriate.



•• Studies have shown that up to 50% of people with Studies have shown that up to 50% of people with substance disorders have a co-occurring psychiatric illness. substance disorders have a co-occurring psychiatric illness. Of all psychiatric co-occurrences, substance use disorders Of all psychiatric co-occurrences, substance use disorders are particularly prevalent in clients with psychotic disorders are particularly prevalent in clients with psychotic disorders such as schizophrenia.such as schizophrenia.

•• The rates of substance use disorders in people with The rates of substance use disorders in people with psychotic disorders are much higher than those in the psychotic disorders are much higher than those in the general population in Canada.general population in Canada.

•• People with schizophrenia are almost five times more likely People with schizophrenia are almost five times more likely to have substance use disorders than people without mental to have substance use disorders than people without mental disorders (three-fold higher for alcohol and six-fold higher for disorders (three-fold higher for alcohol and six-fold higher for other illicit drugs).other illicit drugs).

•• Substance abuse can hasten the onset of psychotic Substance abuse can hasten the onset of psychotic disorders, worsen both the symptoms and the course of disorders, worsen both the symptoms and the course of illness, and lead to higher rates of psychiatric hospitalization illness, and lead to higher rates of psychiatric hospitalization and increased health care costs.and increased health care costs.

•• Substance misuse makes diagnosing the type of psychotic Substance misuse makes diagnosing the type of psychotic disorder more difficult. For example, studies have shown disorder more difficult. For example, studies have shown that over 50% of adolescent patients seen in psychiatric that over 50% of adolescent patients seen in psychiatric clinics use substances.clinics use substances.

•• Tobacco is the most used substance by people with a Tobacco is the most used substance by people with a psychotic disorder, followed by cannabis. The prevalence psychotic disorder, followed by cannabis. The prevalence of cigarette smoking is two- to three-fold higher in of cigarette smoking is two- to three-fold higher in patients with schizophrenia (58–88%), compared to that patients with schizophrenia (58–88%), compared to that in the general population.in the general population.

•• Studies have found that the risk of schizophrenia in heavy Studies have found that the risk of schizophrenia in heavy cannabis users is six times higher than in non-users, even cannabis users is six times higher than in non-users, even when taking into account things such as other psychiatric when taking into account things such as other psychiatric illnesses and social background.illnesses and social background.

•• If alcohol is involved, patients with psychotic disorders If alcohol is involved, patients with psychotic disorders more typically have a diagnosis of alcohol abuse rather more typically have a diagnosis of alcohol abuse rather than dependence, and tend to engage in “binge” drinking than dependence, and tend to engage in “binge” drinking instead of regular alcohol use.instead of regular alcohol use.

•• Evidence suggests that the risk of schizophrenia or Evidence suggests that the risk of schizophrenia or psychosis is higher in those who use drugs than those psychosis is higher in those who use drugs than those who don’t because of genes or brain abnormalities who don’t because of genes or brain abnormalities that are shared by the two disorders.that are shared by the two disorders.

•• Ideally, both pharmacological and behavioural treatments Ideally, both pharmacological and behavioural treatments should be combined for the treatment of co-occurring should be combined for the treatment of co-occurring substance use and psychotic disorders.substance use and psychotic disorders.


c o n c l u S i o n S a n d i m p l i c at i o n S f o r c a n a da

Overwhelming evidence reveals the high prevalence of varioussubstance use disorders in persons with psychosis that wreakhavocontheirlives.Butwenowhaveabetterunderstandingofthe risk factors that confer vulnerability to substance use andaddictions in people with psychosis, and are developing bettermedications,behaviouralandsystemsapproachestomanagethisco-occurrencemoreeffectively.Nonetheless,ourcurrenthealthcaresystemisnotwellequippedtomanagetheseclients.Changestooursystemsfortrainingmentalhealthandaddictionsstaffandphysicians,aswellasreconfiguringthehealthcaresystemtobetterservethecomplexneedsoftheseclients,willbecrucialifwearetomakeprogressinthisarea.


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ACalltoACalltoActionActionfranco J. Vaccarino, phd universityoftoronto

franco J. Vaccarino, phd

Dr.FrancoVaccarino,PhD,Dr.FrancoVaccarino,PhD,isafullProfessorintheisafullProfessorintheDepartmentsofPsychologyDepartmentsofPsychologyandPsychiatry,aswellandPsychiatry,aswellasaVice-PresidentoftheasaVice-PresidentoftheuniversityoftorontoanduniversityoftorontoandPrincipaloftheuniversityPrincipaloftheuniversityoftorontoScarborough.oftorontoScarborough.HisinterdisciplinaryresearchHisinterdisciplinaryresearchaccomplishmentsintheaccomplishmentsintheareasofneuroscience,areasofneuroscience,addiction,andmoodandaddiction,andmoodand

anxietysystemshavebeenanxietysystemshavebeenrecognizedinternationally.recognizedinternationally.Dr.Vaccarino’sprominenceDr.Vaccarino’sprominenceinthefieldwasalsorecoginthefieldwasalsorecog--nizedbytheWorldHealthnizedbytheWorldHealthorganization(WHo)inhisorganization(WHo)inhisroleasthePrincipaleditorroleasthePrincipaleditorofitsrecentlypublishedofitsrecentlypublishedNeuroscience of PsychoNeuroscience of Psychoactive Substance Use and active Substance Use and Dependence Dependence reportreport..

author bioauthor bio


i m p u l S i V i t y a n d S u b S ta n c e u S e d i S o r d e r Si m p u l S i V i t y a n d S u b S ta n c e u S e d i S o r d e r S77

Therationaleforconsideringconcurrentmentalhealthandsub-stanceusedisordersatopicofspecialsignificanceisinmanywaysself-evident:thetwodisordersfrequentlycoexist;theyaffectoneanother inclinically importantways;theyoftensharecommonbiological,psychologicalandsocialroots;andtheseco-occurringdisorders representamajorhealthchallenge.Despite themanygood reasons for considering concurrent disorders a subject ofhighpriority,adividecontinuestoexist.Forexample,scientificprograms aimed at better understanding the processes andmechanisms underlying substance use disorders often excludementalhealthdisorders,andviceversa.Atthecommunitylevel,alackofemphasisontheinteractionbetweenmentalhealthandsubstanceusedisorders can sometimes lead toanunderestima-tionof the effect of one conditionon the course of the other.Community addiction programs often deal with substance useand mental health disorders independently, and because treat-ment programs are ill-equipped to deal with both disorders,those suffering from both a substance use and mental healthdisorder commonly receive sub-standard care. In fact, a studylooking at the degree to which recommended basic care wasbeingfollowedforanumberofdifferentconditionsidentifiedthatthequalityof care variedgreatlyby condition. It shouldnotbesurprising, then, thatcare for substanceusedisorders scored the

poorestwhenitcametofollowingrecommendedbasicstandardsof care. Concurrent mental health and substance use disordersdidnotevenmakethelist.

Thereisnodoubtthatparallelsystemsofcareforthosesufferingfromonlya substanceusedisorderoramentalhealthdisorderarenecessary;however,parallelsystemsdopresentamajorchal-lengeforthosesufferingfromconcurrentdisorders.Whetherwearetalkingabouthospitals,correctionalfacilitiesorcommunityhealthservices,thelimitedabilityofourclinicalandcommunityprogramstoapproachconcurrentdisordersinacoordinatedandintegratedmanner, represents a significantbarrier toeffectivelytreatingthoseaffectedbyboth.Anessentialfirststeptoovercomingthisbarrieristherecognitionthattheinteractionbetweensub-stanceusedisordersandmentalhealthdisordersisparamounttocareandtreatment.Today,wearebeginningtoseetheemergenceofclinicalandcommunityprogramsthatrecognizethisimportantinteraction, where substance use disorders and mental healthdisordersareseenasbalancedcontributorstotheoverallconditionofaclient.InpublishingthepresentSubstance Abuse in Canada: Concurrent Disorders,CCSA’saimistocontributetothegrowingeffortstoensurethatourapproachestoresearch,educationandcarein the substanceusedisorderandmentalhealthfieldsconsider

an integr ated approach to nationaltreatmentstrategieswillgoalongwaytowarddevelopingaunifiedandcoordinatedsystemforaddressingconcurrentdisorders.


concurrentdisordersasamajorpriority.Tothisend,thepresentreportprovidesanoverviewofstate-of-the-artfindingsandhigh-lightsanumberofkeyareaswhereadvancesinourunderstand-ing of concurrent disorders have provided a solid platform onwhich to build treatment, research and educational efforts toimprovecareandtransformthesystemsupportingcare.

Inthiscalltoaction,wedrawontopicsexploredinearlierchaptersandusethisfoundationasanimpetustoexplorefutureprioritiesinthesubstanceabusefield.Webeganthisreportbyexploringwhytheissueofconcurrentdisordersissoimportantandwhyanintegrated approach is essential. This led to a more in-depthdiscussionoftheinterplayofvariousmentalhealthproblemswithsubstanceusedisorders.Thechaptersonanxiety,stress,traumaand impulsivity underline the importance of individual andpersonality factorsaswell as environmental anddevelopmentalconsiderations.The chapter on impulsivity further emphasizestheimportanceofthisbehaviouraldimension;itcutsacrossmentaldisordersandiscentraltosubstanceusedisorders.Thefinaltwochaptershighlighttheinterplaybetweensubstanceusedisordersandthemajormentalillnesses:psychosis,depressionandbipolardisorder.Together,theseconditionsrepresentmajorcontributorstodeathanddisabilityworldwideandwarrantspecialconsiderationwith respect to the contribution of substance use disorders totheirdevelopmentandclinicalcourses.

Fromthesechaptersanumberofthemesarisethatdemandacalltoaction.

c o n c u r r e n t d i S o r d e r S : a n e e d f o r i n t e g r at i o n c o n c u r r e n t d i S o r d e r S : a n e e d f o r i n t e g r at i o n

treatment and care: From the information presented in thisreportitisclearthatamajorproportionofclientswithmentaldisordersbeingtreatedinmentalhealthcentresareusingdrugsof abuse and often have a substance use disorder. Conversely,within addiction care programs, a large number of clients alsohavesignificantmentalhealthproblems.Inthesecases,althoughtheclientdoes receive somecare, this care is typicallynotwellintegrated and under-recognizes the contribution of the co-occurring condition to the course of the primary problem. Inothercases,treatmentprogramsoftenfullyexcludeeitherthosewithsubstanceusedisordersorthementallyill,leavingtheclientwithanunmetserioushealthneedaswellasacombinedsenseofhelplessnessandurgency.

Institutionalaccreditationguidelinesforclinicalcareareagoodexample of the lack of integration. Current accreditation stan-dardsallowinstitutionstochoosebetweenaddictionsormentalhealth standards, thusperpetuating the separationof addictionandmentalhealthknowledge—anditsapplicationtotreatmentandcare.Today,aswebetterunderstand the significantunmetneedinpeoplesufferingfromconcurrentdisordersandnowthatwe have the requisite knowledge base to justify an integratedapproachtotreatmentandcare,ourpresentsystemwithitsgenerallackofintegrationisnoteasilyjustifiable.

Clinical practice guidelines and standards in the substance Clinical practice guidelines and standards in the substance use disorder and mental health fields need to be integrated use disorder and mental health fields need to be integrated and should reflect a unified national approach for the treatment and should reflect a unified national approach for the treatment and care of those suffering from concurrent disorders.and care of those suffering from concurrent disorders.

education and training:Notonlydoesthisreportchallengeoursystemoftreatmentandcaretointegratesubstanceusedisordersandmentalhealthdisorders,butitalsocallsforoureducationalsystemtodo the same.Whilemuchremains tobe learned,we


a c a l l t o a c t i o na c a l l t o a c t i o n

haveasufficientunderstandingofconcurrentdisorderstoincor-poratefindingsintoforward-lookingbestpracticesthatrecognizethe integrated nature of substance use disorders and mentalhealthdisorders.Thebestpractices that emerge from thisnewknowledgewillbeadeviationfrompastapproaches,astheywillfocusonbridging theknowledge in the substanceusedisorderandmentalhealthfieldstowardsthedevelopmentofacommon,unifiedapproach.Developingthisintegratedknowledgeofconcur-rentdisordersfromexistingfindingsandapplyingthisknowledgetooureducationalprograms—whether in thementalhealthorthe addictions field—is essential and would constitute a majorreorganizationofourapproachtoeducation.

A successful response to concurrent disorders requires trainedprofessionalswhohaveacommonunderstandingofconcurrentdisorders and who work within a framework shared by othertrainedprofessionalsinthefield.

A common educational platform with new specialized training A common educational platform with new specialized training programs needs to be created. This would help achieve a programs needs to be created. This would help achieve a common foundation of understanding and would help facilitate common foundation of understanding and would help facilitate the integration of system services.the integration of system services.

Acommoneducationalplatformwouldbesharedbyhealthpro-fessionalsfromdifferentsectorswhosharethecommonpurposeofaddressingclinicalcarechallengesofclientswithconcurrentdisorders.

research:Thepresentreportmakesitclearthatwhetherwearespeakingofdiscoveryresearchormoreappliedresearch,emerg-ing frameworks for understanding processes underlying sub-stanceusedisordersandmentaldisorderscontinuetohighlightthecommonalitiesandinteractionsbetweenthetwo.TheCIHRrecognizedthisatitsinceptionwiththecreationoftheInstituteforNeuroscience,MentalHealthandAddictionasacoreelementofthefederalsystemforfundingCanadianhealthresearch.Itisnowtimeforgovernmentsandothersectorsthatsupportresearchtonotonlyrecognizetheenormousclinicalburdenrepresentedby

concurrent disorders and the human cost of these disorders toour health care system, but also to prioritize the vast researchopportunityrepresentedbythisfield.

Oneparticularresearchneedisforafocusednationalapproachtoclinicalresearchonconcurrentdisorderswiththegoalofdevel-opingnational standardsandnewbestpractices forconcurrentdisorders.Thishasbeensuccessfulinotherareas,suchasAIDS;the success of coordinated national efforts in clinical researchwithintheAIDSfielddemonstratestheremarkableeffectivenessofanationalclinicalresearchstrategyfordevelopingsolutionstotrans-disciplinaryhealthchallenges.

The addictions and mental health communities must come The addictions and mental health communities must come together to effectively seize the resources and momentum together to effectively seize the resources and momentum necessary to address the current gap in research and necessary to address the current gap in research and research funding within the concurrent disorders field. research funding within the concurrent disorders field.

WithinCanada,theVancouverEastSideisacompellingexampleof the economic and social costs of not addressing the clinicalresearch needs of substance use disorders, mental health issuesandconcurrentdisorders.

the System:Currently,separatenationaladdictionsandmentalhealthtreatmentstrategiesexistthathighlightsystemneedsandpriorities.Aswemoveforward,itwillbeimportanttointegratenationaltreatmentstrategiesinthementalhealthandsubstanceusefields.

An integrated approach to national treatment strategies An integrated approach to national treatment strategies will go a long way toward developing a unified and coordinated will go a long way toward developing a unified and coordinated system for addressing concurrent disorders. system for addressing concurrent disorders.


d e V e l o p m e n ta l c o n S i d e r at i o n S : d e V e l o p m e n ta l c o n S i d e r at i o n S :

a c a S e f o r f o c u S i n g o n a d o l e S c e n c e a c a S e f o r f o c u S i n g o n a d o l e S c e n c e

Muchoftheknowledgepresentedinthisreporthighlightscon-ditionsthataredevelopmentallysensitive.Giventhattheonsetofsubstanceusedisordersiscommonduringadolescence,ourlastSubstance Abuse in Canada reportwasdedicated to a focusonyouth.Itemphasizedbiological,psychologicalandsocialreasonswhyyouthandadolescencedeservespecialattention.Theimpor-tanceofyouthasatargetpopulationisfurtherreinforcedinthepresentreportforreasonsrelatingtothedevelopmentalnatureofmanymentalhealthdisorders.

Inrecentyears,increasedeffortshavebeendirectedatprogramsthatfocusonearlydetectionandinterventionofmentalhealthdisorders.Theprioritizationofearlydetectionandinterventionin the mental health field speaks to emerging knowledge thatindicates many mental health disorders have a strong develop-mental trajectory with an onset often linked to the adolescentperiod. Indeed, emerging knowledge in the field supports thenotionthat,inmanycases,mentalhealthdisorderscanactuallybecharacterizedasdevelopmentaldisorders.Discussionsinthisreportindicateearlyonsetofavarietyofmentalhealthdisordersincluding impulse control disorders, anxiety disorders, mooddisorders and schizophrenia. Together with last year’s reporthighlightingyouthandadolescenceasthesensitivedevelopmentalperiodfortheonsetofsubstanceusedisorders,thepresentreportcallsforthisperiodtobeconsideredacriticalonefortheemergenceofconcurrentdisorders.

Not only is integration necessary with respect to research, Not only is integration necessary with respect to research, education and care, but a particular developmental focus education and care, but a particular developmental focus on youth and early detection is also called for as we tackle on youth and early detection is also called for as we tackle the challenges of concurrent disorders. the challenges of concurrent disorders.

e a r ly d e t e c t i o n , e a r ly i n t e rV e n t i o n a n d e a r ly d e t e c t i o n , e a r ly i n t e rV e n t i o n a n d

r a i S i n g awa r e n e S Sr a i S i n g awa r e n e S S

This report highlights findings that demonstrate the presenceof sub-clinical indicators, aswell as environmental andgeneticdeterminants of vulnerability to concurrent disorders. Thesefindingsrepresentnewtoolstohelpidentifyindividualsandgroupsatriskforfutureemergenceofafull-blownconcurrentdisorder.Asisthecaseinotherhealthconditions,concurrentdisordersarebesttreatedwheninterventionisearly,andmayevenbepreventablewithawarenessofsub-clinicalindicatorsandotherdeterminantsofvulnerability.

There is a need to ensure that we have practices in place There is a need to ensure that we have practices in place to identify individual and group risk factors early, and to to identify individual and group risk factors early, and to intervene with integrated care programs aimed at preventing intervene with integrated care programs aimed at preventing concurrent disorders. concurrent disorders.

S t r e S S , t r a u m a a n d e x p e r i e n c eS t r e S S , t r a u m a a n d e x p e r i e n c e

Thisreporthasalsohighlightedthe importanceofstressful lifeexperiencesasariskfactorfordevelopingsubstanceusedisordersandmentalhealthdisorders.Whilethesetwoeffectsofstressfullife experiences have often been studied independently, theeffectsofstressorsonbothconditions —asthisreportdiscusses—canbeseenasaunifiedphenomenonthatpointsouttheimportantinterplaybetweensubstanceusedisordersandmentaldisorders.Thisriskconferredbystressfullifeeventsonconcurrentdisorderscan also be seen as both environmentally and developmentallyrelevant.Whilestressisariskfactorforsubstanceusedisordersthroughoutthelifespan,itisespeciallyrelevantduringadolescence,aparticularlyvulnerableperiodforthedevelopmentofsubstanceuseandmentalhealthdisorders— orboth.

Togetherwithdiscussionsconcerningthecoexistenceofanxietyandsubstanceusedisorders,thepresentreportunderlinestheneedto attend to risk factors associatedwith stress and stressful lifeexperiences.Whiletherelationshipbetweenstress,trauma,sub-stanceusedisordersandmentalhealthdisordersiscomplicated,asufficientbodyofknowledgeexiststobegintodevelopintegrated


a c a l l t o a c t i o na c a l l t o a c t i o n

approachestopreventionandtreatmentthatarecommontothesubstanceuseandmentalhealthfields.Whilethementalhealthfieldhasmadeeffortstosystematicallyincorporatebiologicalandpsychological knowledge associated with the effects of stressfullifeeventsintoitseducationalandtreatmentprograms(e.g.,stressappraisalandcopingmechanisms,stressmanagement,etc.),theaddictionfieldneeds tocontinue tobuildon its efforts in thisregard.Buildingontheexistingbodyofknowledgeintheareaoflifestressorsandtrauma,thisfieldpresentsasignificantopportunitytoworktowardsanintegratedandunifiedapproachtopreventionandtreatmentstrategies.

c o n c l u S i o nc o n c l u S i o n

A sustained and serious commitment to concurrent substanceuse andmental healthdisorders represents a significantunder-takingthatwillrequireconsiderablecommitmentonthepartofpolicy makers, educators, researchers and health professionals.While the goal of integration of mental health and addictionservicesmayseemdaunting,itmustbevigorouslypursuedandpromoted.Indeed,thisprocesshasalreadybegunasevidencedbythe existenceof particular institutions and centres bothwithinand outside government that have, in recent years, identifiedintegrationofsubstanceuseandmentalhealthdisorderservicesasnecessary.Movingforward,itwillbeimportanttoestablishacommon national framework for understanding the interplaybetweensubstanceusedisordersandmentalhealthdisordersandtoestablishaunifiedapproachtothecareandtreatmentofthoseaffectedbyconcurrentdisorders.Theseeffortswillbeneededinordertoeffectivelyaddressthechallengesfacedbythosesufferingfrom concurrent disorders and to more effectively coordinateservicesbetweenthetwosectors.

substance abuse in canada: concurrent disorders · substance abuse in canada: concurrent disorders...

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