Nida Takes on Co-occurring Illness

Peter J. Dorsen, M.D., LADC

Nora Volkow, M.D., Director of the National Institute of Drug Abuse (NIDA), in a recent research report, notes: “ Drug addiction is a mental illness.” She also emphasizes that with addiction, drug-induced changes in brain structure and function occur in some of the same brain areas (as) mental disorders…” Wow! Like we didn’t know this already? Unfortunately, society at large fails to put two and two together (if you will excuse the pun here) and believe that collaborative treatment is a must.

Major populations seem to be slipping through the cracks when it comes to treating those saddled unfortunately with the duality of drug dependence and maybe a preexisting mental challenge: schizophrenia, PTSD, bipolar disorder, you name it. Our prisons are teaming with co-morbidity (75% of offenders at the state or local level have co-morbidity yet “ services are greatly lacking within these settings.”

What about all those brave men and women returning from Afghanistan or Iraq with PTSD ( maybe even 38,000 in the past five years!). You’re damned if you do and damned if you don’t. It’s a case of the lumpers and splitters once again: PTSD programs that don’t accept individuals with active substance problems versus traditional substance abuse clinics (SUDs) clinics who defer treatment of trauma-related issues (combat or noncombat).

When it comes down to discrepancies of treatment there is even an implicit paradox that physicians run the mental health facilities and WILL treat with antipsychotics and anxiolytics while substance abuse venues are skewed to treating just that and may not even have personnel who can or will prescribe despite the predominance of co-morbidity.

Volkow and her team from NIDA emphasize that there is a 40-60% vulnerability to addiction attributable to multiple genes, genetic interactions, and environmental influences. One can joke as one way of relieving angst how mental illness and substance abuse co-mingle by wondering if such predilections start with the drinking water. The study correlates psychosis and marijuana use, how nicotine may lessen symptoms of schizophrenia (a 90% rate of smokers). They note a significant association between mental illness and smoking: “schizophrenics have higher rates of alcohol tobacco, and other drug use.”

They remind us how the neurotransmitter dopamine is pivotal; that it is affected by addicted substances as well as depression, schizophrenia, and other psychiatric disorders.

The chaotic process often begins in adolescence: abusing “gateway” drugs and mental illness. I can relate yet all we had in the sixties was alcohol and nonetheless did a pretty fair job at abusing it. Currently, educators like Dartmouth’s President Kim spend anxious reflective moments disturbed by fears when the next undergraduate will die from alcohol on his campus.

We have on our table promising behavioral therapies that include multisystem therapy (MST) dealing with attitudes, family, and peers; brief family therapy (BSFT) for the oppositional-defiant youngster with a conduct disorder; cognitive behavioral therapy (CBT) helping us change harmful or maladaptive beliefs; therapeutic communities (TC’s) for resocialization, the neglected youth; assertive community treatment (ACT) with an individual approach; dialectical behavioral therapy (DBT) especially for the borderline personality who will self harm; exposure therapy (ET) to create real or simulated reruns and remove fear; and integrated group therapy (IGT) great for bipolar disorder and drug addiction.

The NIDA report is filled with theme and substance offering new ideas for approaching co-occurring illnesses. I heartily recommend obtaining the full report to explore further the direction thinking and treatment must go to better deal with these two illnesses. Not only do they appear to exist in the same part of the brain but should and can be treated better simultaneously often with the right medications and therapy.