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Chapter 38. The Mentally Ill Substance Abuser

Stephen Ross, M.D.
DOI: 10.1176/appi.books.9781585623440.355147

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Although substance use disorders (SUDs) occur commonly in the psychiatrically ill, they are often underrecognized and undertreated. This has dire consequences for both individual patients and society in general. The immense economic burden of alcohol- and drug-related disorders alone and their associated adverse consequences has been estimated to cost the United States $375 billion annually (Office of National Drug Control Policy 2001). Moreover, in comparison with patients with only a mental illness or an SUD, patients with co-occurring mental illness and an SUD across a broad spectrum of diagnostic types and combinations have greater severity of illness and a worse longitudinal course of illness in multiple domains, including increased risk for psychiatric and substance use relapses; higher rates of recidivism; higher levels of psychological distress; poorer psychosocial functioning; worse treatment retention; poor medication compliance; higher rates of violence, suicide, legal difficulties, medical problems, and family stress; and higher utilization of health care services such as emergency department and inpatient services (Hser et al. 2006; Mueser et al. 1998; Ziedonis 2004).

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TABLE 38–1. Co-occurring severity matrix
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TABLE 38–2. Prevalences of current and lifetime alcohol use disorders (AUDs) and drug use disorders (DUDs)
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TABLE 38–3. Prevalences of current and lifetime specific drug use disorders
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TABLE 38–4. Diagnostic formulation
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TABLE 38–5. General principles of psychotropic interventions in the dually diagnosed
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TABLE 38–6. Medications for treatment of substance use disorders
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In comparison with individuals who have a mental illness or a substance use disorder (SUD) alone, those with a co-occurring mental illness and SUD have a greater severity of illness and a worse longitudinal course of illness.

SUDs co-occur with mental illness at higher rates than they occur in the general population in individuals without mental illness and they occur at higher rates than would be expected by chance.

Of all non-SUD Axis I disorders, schizophrenia has the highest rate of comorbidity with any SUD when considering its co-occurrence with nicotine dependence. Excluding nicotine, bipolar disorder has the highest co-occurrence of any non-SUD Axis I disorder with an SUD.

The clinician treating a patient with co-occurring mental illness and SUDs should use multiple sources of information as well as serial longitudinal assessments to increase the reliability and validity of diagnoses rather than relying on single sources or assessments, especially those done in acute settings.

Substance-induced psychosis with phencyclidine, methamphetamine, and chronic, heavy alcohol use can last as long as several weeks to months, even in patients without an underlying psychotic spectrum illness.

From a systems perspective, integrated treatment is the optimal model as compared with serial or parallel treatment paradigms, especially when comprehensive services are provided.

Of the antipsychotics, clozapine has the most evidence supporting its ability to decrease both psychotic symptoms and substance abuse in patients with co-occurring schizophrenia and an SUD.

There is indirect evidence to support using anticonvulsants (i.e., valproic acid) as first-line agents in treating patients with bipolar disorder comorbid with SUDs. However, lithium and lamotrigine should also be considered because there are some data indicating their effectiveness in reducing both affective symptoms and substance abuse in this patient population.

As a general rule of thumb in treating patients with co-occurring disorders with psychotropic medication, it is prudent to start with a medication that has the least addictive liability as well as having a broad spectrum of activity in terms of treating symptoms of both mental illness and substance abuse.

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According to the Epidemiologic Catchment Area (ECA) study and the National Comorbidity Survey (NCS), the lifetime prevalence of any alcohol use disorder (AUD) ranged from. . .
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