Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
Drug use disorders are frequently associated with mental disorders. Data from the Epidemiologic Catchment Area (ECA) study (Regier et al. 1990) showed that over half (53 percent) of individuals who have a lifetime diagnosis of a drug use disorder also have a lifetime diagnosis of a mental disorder.
Approximately two-thirds of individuals with a cocaine or opiate use disorder have, at some point in their lives, had a mental disorder. For those with a lifetime diagnosis, 15 percent have had a drug use disorder.
Twenty-eight percent of schizophrenics and 42 percent of those diagnosed with antisocial personality disorder have had a drug use disorder. Despite the common co-occurrence of drug use disorders and mental disorders, persons who have both of these problems tend to fall between the cracks of service delivery systems.
Individuals with mental disorders who seek treatment in the community may receive it within the mental health services system, and drug-addicted individuals may receive treatment within the drug abuse treatment system.
Those requiring treatment for both mental and drug use disorders may not be able to receive comprehensive treatment in one treatment program. In the worst case scenario, the clinicians responsible for the treatment of the mental disorder may not have any idea about what is going on with the addictive disorder (e.g., treatment or severity) and the clinicians responsible for the addiction treatment may not be aware of what is happening with the mental disorder.
Unfortunately, those persons who have concurrent mental and addictive disorders are not easily accommodated by the current treatment delivery system. Having separate service delivery systems and separate Federal institutes funding research on mental and addictive disorders has generally fostered the separation of mental health and addictive disorder research.
Typically, research on the treatment of mental disorders is addressed within the research programs of the National Institute of Mental Health, while research on the treatment of drug addiction is addressed within the research programs of the National Institute on Drug Abuse. Research on both drug use and mental disorders may, at times, be viewed with skepticism by reviewers who value the "homogeneous" samples needed to decrease "error variance."
It is entirely plausible, however, that there are circumstances in which different individuals with the same set of mental and drug use disorders are more alike than different individuals who have only one disorder.
Assume, for example, that there are many types of depression and many possible etiologies of depression. From this assumption, it is clear that a study of people with depression is a study of a very heterogeneous group of people.
Assume, also, that nicotine affects only people with a certain type of depression in a certain way, and that these are the people who become addicted to nicotine. In this scenario, those individuals who have a homogeneous type of depression coupled with nicotine addiction may be more like each other than a group of heterogeneously depressed people who are not addicted to nicotine.
This scenario seems quite possible in light of Glassman's work (this volume) on the relationship between depression and nicotine. Research on the treatment of individuals with comorbid mental and addictive disorders holds promise for a greater understanding of the relationship among these disorders and the potential for better treatments.
To date, however, research in this area has been limited. A meeting was held on September 27 and 28, 1994, to highlight some of the ongoing research in this area and to stimulate further research. Not only was research on the treatment of comorbid mental and addictive disorders addressed, but the additional problem of human immunodeficiency virus (HIV) in the context of these comorbid disorders was a topic of focus.
The findings presented at the meeting could not be viewed as a definitive statement on this complex subject. On the contrary, only a limited number of combinations of comorbid mental and addictive disorders have been researched, and no one type could be fully addressed within the confines of any one meeting.
The meeting was chaired by Lisa Simon Onken, Ph.D., Jack Blaine, M.D., Sander Genser, M.D., M.P.H., and Arthur MacNeill Horton, Jr., Ed.D. of the National Institute on Drug Abuse. Presentations were given by David Barlow, Ph.D., Robert Brooner, Ph.D., Kate Carey, Ph.D., Linda Cottler, Ph.D., Francine Cournos, M.D., John Docherty, M.D., Alexander Glassman, M.D., Bridget Grant, Ph.D., Edward V. Nunes, M.D., Kim Mueser, Ph.D., Bruce J. Rounsaville, M.D., Paul Satz, Ph.D., Andrew Shaner, M.D., and George Woody, M.D.
The presentations given by these scientists underscore the promise that research on comorbid mental and addictive disorders holds for future treatment advances and resultant public health benefits. Just as the meeting could not fully address the full range of comorbid mental and addictive disorders and associated HIV issues, neither can this monograph.
However, the chapters that follow, written by many of the participants of the meeting, are examples of exciting research being done in this important area, and they help to define the need for further research. It is the hope of all the editors of this monograph that the readers will be inspired by the contributions that follow.
Regier, D.; Farmer, M.E.; Rae, D.S.; Locke, B.Z.; Keith, S.J.; Judd, L.L.; and Goodwin, F.K. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA 264:2511-2518, 1990.
Lisa Simon Onken, Ph.D. Jack D. Blaine, M.D. Sander Genser, M.D., M.P.H. Arthur MacNeill Horton, Jr., Ed.D. Division of Clinical Research National Institute on Drug Abuse 5600 Fishers Lane Rockville, MD 20857
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NIDA Research Monograph, Number 172