Module 4: Comorbidity and the role of family and friends

Question 1

How comorbid is substance abuse with other symptoms?

Answer 1

50% of those treated for addiction have another mental disorder. The most common include mood disorders, anxiety disorders, personality disorders and ADHD. Some complains can be worsened by substance abuse.

Question 2

Opinions on supporting those with substance abuse

Answer 2

Some believe you should disconnect or may blame themselves and have to deal with sadness, depression, anger, confusion, powerlessness and insecurity. Can be conflicts, domestic violence, financial problems and disrupted relationships with children. Have more relationship problems.

Question 3

Johnson intervention

Answer 3

Involves confrontation and is radical and direct. Seen as last chance to reach out and rescue the addict

Question 4

AI Anon

Answer 4

Based on 12 steps of AA and the aim is to help close relatives accept they are powerless and help them detach with love

Question 5

CRAFT method

Answer 5

Protocolized treatment where close relatives are supported by practitioner to adjust behaviour to motivate the patient to start treatment. Based on CBT and MI. Important elements include:
- functional analysis
- emergency plan
- positive reinforcement of desired behaviour
- not rewarding unwanted behaviour
- improving quality of own life
- propose to start treatment
- communication training

Question 6

BCT

Answer 6

Close relative actively involved in treatment. Aims are: teaching effective ways to cope with substance, teach partner to reinforce behaviour change and improve relationship satisfaction and reduce stress by enhancing positive reward exchanges, boosting communication patterns and problem-solving. Has a large effect on relationship satisfaction but a weak-moderate effect on substance abuse, but relationship satisfaction is a protective factor. Only used when individual therapy is ineffective and severe triggering relationship issues.

Question 7

What affects comorbidity?

Answer 7

Can range from 12-80% which depends on sample recruitment characteristics for example being in a primary care setting, not seeking treatment and drug of abuse. Variations can be due to availability and accessibility of substances, drug treatment policies and methodological differences

Question 8

Epidemiology

Answer 8

• most prevalent diagnosis was major depression (17%) and induced depression was 10%. Drug use showed that more than half the sample actively consumed more than 1 substance
• alcohol use disorder ranges from 2% to 4% and lifetime prevalence 13%, with MD is 21%
• cannabis use associated with alcohol at an early age correlates with comorbid psychiatric disorder
• patients with depressive disorder more likely to be nicotine dependent
• those with nicotine dependence more likely to develop mood disorder
• comorbid SUD and MD more likely in female European population

Question 9

Why could there be a high joint occurrence of SUD and MD?

Answer 9

• share common risk factors
• use of substances induces neurobiological changes which can mediate MD
• SUD can soothe MD symptoms
• common symptoms between addiction and mood disorders

Question 10

Neurobiological mechanisms?

Answer 10

• monoaminergic neurotransmission systems
• hypothalamus pituitary axis
• immunological system
• neurotrophic factors
• endocannabinoid system
• food intake, metabolism and circadian rhythm control system
• reward circuits

Question 11

Issues with differentiating between MD and SUD

Answer 11

• acute or chronic effects of substance use can mimic MD symptoms
• MDs are syndromes as they do not have identifiable biological markers
• structured interviews based on behavioural symptoms can maximize the extent to which information an be applied to the same criteria to achieve diagnosis
• methodological differences can lead to differences in prevalence
  -PRISM demonstrates good psychometric properties

Question 12

How to differentiate MD symptoms from being independent to substance-induced MD?

Answer 12

• Independent (excessive amount of substance, symptoms precede substance use, symptoms persist after withdrawal
• induced (episode occurs during substance use and is relevant to the disorder
• expected effects are physiological effects due to intoxication
• one form is a sudden change in substance intake before onset of depressive symptoms -> induced by SUD
• depressive symptoms during stable consumption or after withdrawal, family history of depression, good response to antidepressants suggest independent depression

Question 13

What is the course and prognosis?

Answer 13

When diagnosed with induced MD or MD with SUD, when reevaluated were reclassified as being affected by independent MD. Could be due to higher probability of induced disorder with drug dependence or alcohol, or that those more vulnerable for MD was precipitate by substance use. Diagnosis for MD was masked by substance consumption. Those that have both SUD and MD show a more severe clinical course but less response to treatment. CAn manifest in other medical, psychiatric and substance use comorbidities

Question 14

Pharmacological treatment

Answer 14

• antidepressant drugs improve comorbid depression with alcohol dependence but not depression that occurs with cocaine or opiate dependence. SSRIs found not to be effective
• treating depressed substance-dependent patients with antidepressants does not directly improve substance use. There is some reduction but not on abstinence or total remission
• depression medication and alcohol dependence medication reduces symptoms of both disorders
• safety of treatment due to comorbid physical illness and risk of interactions with other drugs
• potential for abuse of certain drugs

Question 15

Psychosocial interventions

Answer 15

Can be a growning number of combined treatments available, data about MI and CBT show no superiority, can significantly correlate with alcohol abstinence and nonsignificantly with MD outcome. The effect sizes are smaller for CBT treatments than antidepressants. BRIGHT uses a community-based effectiveness trial which compares residential substance abuse treatment with residential treatment. Showed better clinical outcomes with adherence to treatment and improvement in severity of depressive symptoms. Treatment of comorbid MD and SUD need to take both disorders into account.

Question 16

Why is integrated treatment important?

Answer 16

In European countries, substance abuse and mental illness are dealt with different networks and abstinence from drug use is a requirement to being admitted to treatment for depression. Embraces simultaneous and coordinate treatment to maximize treatment adherence and outcomes.

Question 17

Neurobiological risk factors for comorbid anxiety and substance use

Answer 17

• modest genetic risk
• impaired sertonin and GABA neurotransmission which also mediate the effects of alcohol as it enhances GABA neurotransmission and chronic alcohol intake is linked to serotonin deficit
• impairments of benzodiazepine receptor is involved, neuropeptide S in amygdala and anxiolytic effects of alcohol
• gene variants for HPA activation and its dysfunctions have been linked to anxiety
• prefrontal cortex important in neurobiology of anxiety

Question 18

What is the prevalence rate for anxiety disorders?

Answer 18

Lifetime prevalence is 28.8% and 12-month prevalence is 18.1% Women have a 2/3 fold increased risk for GAD

Question 19

What is the epidemiology of anxiety comorbid with substance use?

Answer 19

• Most studies are cross-sectional, but studies show a 2/3 fold increased risk for alcohol use in people with anxiety
• Odds ratio for alcohol use disorder and GAD was 2 for 12 months and 2.2 for lifetime, for dependence was 3 and 2.8. Show dependence on nicotine and drugs but mot abuse
• Men use more alcohol and drugs to relieve GAD symptoms
• risk factors include: family history of dependence anxiety/depression, childhood trauma, smoking, drug dependence and early onset of anxiety/depression

Question 20

What is the course of comorbidity?

Answer 20

• anxiety symptoms from detoxification or intoxication but often improve and vanish
• no association with anxiety and association of phobias with onset of alcohol use but modest association between specific phobias and later onset alcohol use
• social phobia and panic attacks predicted alcohol problems
• drinking above sensible limits increased the risk for psychiatric disorders but especially for anxiety. But for men, a low to moderate alcohol intake had a protective effect
• incidence rates were greater among men for substance use but greater for women for mood and anxiety disorders
• substance use disorders did not predict any incident mood or anxiety disorder but baseline bipolar predicted drug abuse and baseline PD predicted incident drug dependence

Question 21

What has been found about the relation between anxiety and substance use?

Answer 21

Substance dependence precedes anxiety disorders, especially PD then social phobia and agoraphobia. Anxiety first in 50% of substance use disorder cases

Question 22

What are gender issues?

Answer 22

Women with substance use disorders more likely to have a comorbid anxiety disorder then men and a lifetime anxiety diagnosis led to poorer drinking outcomes even though they drank less

Question 23

Self-medication theory

Answer 23

• Alcohol can have relaxing, tension and stress reducing and sedating effects, short term consumption can diminish anxiety
• Anxiety precedes substance use in most cases
• due to expectancy of drug’s effect
• can be used to reduce anxiety and medicate their stress
• self-medication led to an increased risk of onset substance use disorders and increased risk of social phobia, PD also predicted self medication

Question 24

How can substance use lead to anxiety?

Answer 24

• can worsen psychiatric symptoms and is a symptom in alcohol and drug withdrawal. Could be part of protracted withdrawal syndrome
• Repeated withdrawal syndromes could trigger or kindle anxiety disorders, due to epigenetic mechanisms and role of amygdala
• can share some common causes like childhood trauma and genetics

Question 25

How can prevention strategies be used?

Answer 25

These should be aimed at younger individuals as alcohol problems and negative life events can predict alcohol dependence incidence to identify those at risk

Question 26

Treatment tendencies for those with dual disorders

Answer 26

Treatment-seeking is low but increases with severity of personal problems and highest in those with anxiety and depression. Led to poorer treatment response and outcome, more personal and social problems and impairment. Anxiety symptoms can decrease after detoxification. Persisting anxiety disorders should be treated first with psychotherapy like exposure therapy.

Question 27

Problems associated with substance use

Answer 27

Negative impact on lives of family members and friends, marital distress, social problems, financial troubles, aggression and interpersonal violence. Associated with depression, PTSD, anxiety, low self-esteem and physical symptoms

Question 28

What have recent advances suggest about AI Anon and Johnson?

Answer 28

That those struggling with addiction are not powerless and that disconnection is counterproductive

Question 29

What is the core principle of CRAFT?

Answer 29

Environmental contingencies are important in treating the individual and reducing psychical and psychological distress

Question 30

What was the criteria of the studies selected?

Answer 30

• RCT
• CSOs of treatment resistant individuals with substance use disorders
• CRAFT or AI Anon or Johnson trained therapists that had supervision
• primary goal to encourage treatment resistant IP to go into treatment

Question 31

What did results find?

Answer 31

That CRAFT was the most effective for CSOs to motivate IPs, followed by Johnson Institute and AI Anon. There were improvements found in depression, anger, quality of relationships, family cohesion, family conflicts and improved functioning. CRAFT produced a rate of 67% while AI Anon had an engagement of 18%, while Johnson had 30%.

Question 32

Effectiveness compared to each treatment

Answer 32

• strong evidence that CRAFT is superior to AI Anon
• limited evidence that CRAFT is superior to Johnson institute

Question 33

What was found about functioning across the treatments?

Answer 33

The CSOs had similar improvement in CSO functioning, but strong evidence that CRAFT and AI Anon improve CSO functioning but limited evidence that the Johnson Institute intervention improves functioning of CSO

Question 34

Clinical implications

Answer 34

Suggests that CRAFT holds promise to be an effective treatment option in improving the functioning of CSOs and their wellbeing. There is ore support from uncontrolled studies in practice which have robust outcomes-> psychosocial improvements and decrease in symptoms. Some studies found to be less effective but due to heterogenous populations. Has been effective on parents of treatment-resistant adolescents, engagement completed from 4-6 sessions and works on many relationships.

Question 35

Research implications

Answer 35

Change talk (commitment to change) is an important predictor of outcome and future research should focus on communication style to get more in-depth innformation on interaction mechanisms. Focusses on empowerment by giving knowledge and depends on skills training to promote self-reliance and self-care-> independence and improved self-esteem. Works based on self-efficacy mechanism. Studies have found that CRAFT decreases alcohol and drug use before engaging in treatment and reduces life-threatening behaviours like IPV. Does so by exploring antecedences and consequences of IPV and avoidance and coping strategies of domestic violence.

Question 36

Limitations

Answer 36

• more info on method led to higher method scores
• use of alcohol and drugs can cause misconception of results
• unclear whether delivered authentically and a non-treatment group should have been included
• unclear which part in CRAFT is effective (group format, self-help book, more treatments not needed all found to be effective
• can be useful for other psychiatric disorders
• cost benefit analyses should be taken into account