How should comorbid conditions be treated?
A fundamental principle emerging from scientific research is the need to treat comorbid conditions concurrently–which can be a difficult proposition (see "Barriers to Comprehensive Treatment of Comorbidity"). Patients who have both a drug use disorder and another mental illness often exhibit symptoms that are more persistent, severe, and resistant to treatment compared with patients who have either disorder alone. Nevertheless, steady progress is being made through research on new and existing treatment options for comorbidity and through health services research on implementation of appropriate screening and treatment within a variety of settings, including criminal justice systems.
Effective medications exist for treating opioid, alcohol, and nicotine addiction and for alleviating the symptoms of many other mental disorders, yet most have not been well studied in comorbid populations. Some medications may benefit multiple problems. For example, evidence suggests that bupropion (trade names: Wellbutrin, Zyban), approved for treating depression and nicotine dependence, might also help reduce craving and use of the drug methamphetamine. Clearly, more research is needed to fully understand and assess the actions of combined or dually effective medications.
Behavioral treatment (alone or in combination with medications) is the cornerstone to successful outcomes for many individuals with drug use disorders or other mental illnesses. And while behavior therapies continue to be evaluated for use in comorbid populations, several strategies have shown promise for treating specific comorbid conditions (see "Examples of Promising Behavioral Therapies for Patients With Comorbid Conditions").
Most clinicians and researchers agree that broad spectrum diagnosis and concurrent therapy will lead to more positive outcomes for patients with comorbid conditions. Preliminary findings support this notion, but research is needed to identify the most effective therapies (especially studies focused on adolescents).
Examples of Promising Behavioral Therapies for Patients with Comorbid Conditions
Multisystemic Therapy (MST
MST targets key factors (attitudes, family, peer pressure, school and neighborhood culture) associated with serious antisocial behavior in children and adolescents who abuse drugs.
Brief Strategic Family Therapy (BSFT)
BSFT targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co-occurring problem behaviors. These problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behaviors.
Cognitive-Behavioral Therapy (CBT)
CBT is designed to modify harmful beliefs and maladaptive behaviors. CBT is the most effective psychotherapy for children and adolescents with anxiety and mood disorders, and also shows strong efficacy for substance abusers. (CBT is also effective for adult populations suffering from drug use disorders and a range of other psychiatric problems.)
Therapeutic Communities (TCs)
TCs focus on the "resocialization" of the individual and use broad-based community programs as active components of treatment. TCs are particularly well suited to deal with criminal justice inmates, individuals with vocational deficits, women who need special protections from harsh social environments, vulnerable or neglected youth, and homeless individuals. In addition, some evidence suggests the utility of incorporating TCs for adolescents who have been in treatment for substance abuse and related problems.
Assertive Community Treatment (ACT)
ACT programs integrate the behavioral treatment of other severe mental disorders, such as schizophrenia, and co-occurring substance use disorders. ACT is differentiated from other forms of case management through factors such as a smaller caseload size, team management, outreach emphasis, a highly individualized approach, and an assertive approach to maintaining contact with patients.
Dialectical Behavior Therapy (DBT)
DBT is designed specifically to reduce self-harm behaviors (such as self-mutilation and suicidal attempts, thoughts, or urges) and drug abuse. It is one of the few treatments that is effective for individuals who meet the criteria for borderline personality disorder.
Exposure therapy is a behavioral treatment for some anxiety disorders (phobias, PTSD) that involves repeated exposure to or confrontation with a feared situation, object, traumatic event, or memory. This exposure can be real, visualized, or simulated, and always is contained in a controlled therapeutic environment. The goal is to desensitize patients to the triggering stimuli and help them learn to cope, eventually reducing or even eliminating symptoms. Several studies suggest that exposure therapy may be helpful for individuals with comorbid PTSD and cocaine addiction, although retention in treatment is difficult.
Integrated Group Therapy (IGT)
IGT is a new treatment developed specifically for patients with bipolar disorder and drug addiction, designed to address both problems simultaneously.
Barriers to Comprehensive Treatment of Comorbidity
Although research supports the need for comprehensive treatment to address comorbidity, provision of such treatment can be problematic for a number of reasons:
- In the United States, different treatment systems address drug use disorders and other mental illnesses separately. Physicians are most often the front line of treatment for mental disorders, whereas drug abuse treatment is provided in assorted venues by a mix of health care professionals with different backgrounds. Thus, neither system may have sufficiently broad expertise to address the full range of problems presented by patients. People also use these health care systems differently, depending on insurance coverage and social factors. For example, when suffering from substance abuse and mental illness comorbidities, women more often seek help from mental health practitioners, whereas men tend to seek help through substance abuse treatment channels.
- A lingering bias remains in some substance abuse treatment centers against using any medications, including those necessary to treat serious mental disorders such as depression. Additionally, many substance abuse treatment programs do not employ professionals qualified to prescribe, dispense, and monitor medications.
- Many of those needing treatment are in the criminal justice system. It is estimated that about 45 percent of offenders in state and local prisons and jails have a mental health problem comorbid with substance abuse or addiction. However, adequate treatment services for both drug use disorders and other mental illnesses are greatly lacking within these settings. While treatment provision may be burdensome for the criminal justice system, it offers an opportunity to positively affect the public's health and safety. Treatment of comorbid disorders can reduce not only associated medical complications, but also negative social outcomes by mitigating against a return to criminal behavior and reincarceration.
This series of reports simplifies the science of research findings for the educated lay public, legislators, educational groups, and practitioners. The series reports on research findings of national interest.