The tragic escalation of opiate abuse in this country as well as the ongoing healthcare insurance debate over coverage for addiction treatment has focused public attention on the high prevalence and noxious impact of substance abuse on those affected. Over a quarter of Americans suffer from substance use related disorders including alcohol, opiates, cocaine, marijuana and other drugs over the course of their lives. Their impact on overall health, quality of life, and distress is substantial. The costs to society associated with decreased work productivity and increased crime and healthcare utilization run into the hundreds of billions of dollars per year.
Mental health and addiction
An important element to consider when addressing substance use is the presence of co-occurring mood disorders such as depression and bipolar disorder (manic-depression). Over four in ten people with mood disorders have a history of alcohol or other substance abuse. Similarly, at least 40 percent of those with substance use disorders suffer from depression or bipolar disorder over the course of their lifetime.
These mood disorders often occur independently of the direct effects of ingestion or withdrawal of the abused substances. The presence of these co-occurring conditions significantly worsens the course of illness for each condition. Therefore, co-occurring mood disorders need to be addressed in the treatment of patients with addictions and should be assessed in primary care and mental health settings where patients with depression often present for treatment.
Researching treatment options
Unfortunately, there has been a relative paucity of research examining the treatment of comorbid mood and substance abuse disorders, particularly in light of the high prevalence and negative impact associated with these conditions. Traditionally, targeted treatment for mood disorders has been withheld in substance abusers until the patient has been abstinent for a while. This is in order to determine whether, and to what degree, the mood symptoms are attributable to the substance use and because of concerns of potential negative interactions between pharmacotherapeutic agents and the drugs of abuse.
However, the practice of delaying initiation of treatment for mood disorders can be problematic as patients with untreated mood disorders tend to be unable to establish or maintain abstinence and so more quickly return to substance abuse. This is of particular concern given that substance abusers with a history of comorbid depression are significantly more likely to attempt suicide. It suggests that withholding or delaying treatment in these patients may have significant adverse consequences. Thus it is critical to assess and address mood symptoms, in addition to emphasizing abstinence, in patients with these co-occurring conditions.
There is some evidence supporting the use of carefully targeted treatment simultaneously addressing both the mood and substance use disorders, though more research addressing this issue is clearly needed. Attention to the problem of co-occurring mood disorders is warranted, as the nation moves forward in attempting to address the critical public health issues associated with substance abuse.
Mark H Pollack, M.D., Past President, Anxiety and Depression Association of America, [email protected]
