Alcoholism and mental illness: overlapping diseases requiring a renewed focus
This is an Accepted Manuscript of an article published in Mental Health and Substance Use on June 17, 2014, available online: http://www.tandfonline.com/ 10.1080/17523281.2014.939220
Alcohol addiction and psychiatric disorders frequently occur together, and individuals affected by both conditions represent a unique patient population in need of specialized treatment. Decades of research have pointed to promising prospective therapeutic options, yet no standardized diagnostic measures or treatment regimens are available for clinicians or their patients. As a result, patients with both alcohol abuse and mental disorders frequently do not receive specialized treatment that addresses both conditions. Moreover, a great deal of research regarding alcohol use disorder treatment has failed to include patients with co-occurring mental illnesses. To address this serious public health concern, a renewed focus on large-scale trials is required to examine the benefits of various therapeutic practices and delivery methods in the mentally ill, alcohol-dependent population. This commentary will provide a brief overview of the diagnostic and therapeutic challenges associated with treating dually diagnosed individuals, the state of current research strategies, and a potential roadmap for improving the future of research in this field.
Alcohol use, mental health, comorbidity, intervention, dual diagnosis
The scope of the problem
Alcohol abuse and alcohol dependence are two conditions characterized as alcohol use disorders. Alcohol abuse is defined as “continued drinking despite negative consequences and the inability to fulfill responsibilities”. Alcohol dependence, on the other hand, is characterized by a craving for and possibly physical dependence on alcohol, an inability to control one’s drinking, and an increasing tolerance to the effects of alcohol. 1 Alcohol use disorders remain a substantial public health concern, due to the many physical, psychological, and social effects of alcohol abuse. Harmful drinking contributes to disorders of the heart, liver, and gastrointestinal tract, as well as many cancers, and leads to over 2.5 million deaths worldwide annually.2 Infectious diseases such as HIV and other sexually transmitted infections have been linked with alcohol abuse, stemming from risky behavior and possibly from alcohol-induced compromise of the immune system.2
However, alcohol use disorders do not exist in isolation. Among the most common complications are neuropsychiatric disorders. According to the Substance Abuse and Mental Health Services Administration, at least 6.8 million adults suffered both mental illness and substance abuse issues in 2011 (SAMHSA).3 Individuals with an alcohol use disorder are up to three times more likely than unaffected individuals to suffer from an anxiety disorder, and nearly four times more likely to suffer a major depressive episode.4, 5 In turn, co-morbid mental illness complicates substance dependence treatment.
Patients with anxiety disorders may be less likely to seek needed treatment for alcohol dependence.6 Those who do undergo addiction treatment may be more likely than alcohol dependent patients without mental illness to drop out of treatment or to relapse upon completion.7-10 Similarly, the presence and severity of depressive symptoms strongly influences the length of time to relapse following treatment for alcohol addiction.7-9, 11-13 Post-traumatic stress disorder (PTSD) is highly comorbid with alcohol dependence.14, 15 Abstinent patients suffering from both alcohol use disorders and PTSD tend to relapse faster than those with other DSM-Axis I psychiatric disorders.14
In short, there is a great need to understand how to manage the intersection of alcohol problems and mental illness. Unfortunately, despite years of effort, diagnosis and treatment of mental illness or substance abuse issues alone remains difficult, and research has not adequately untangled the two. As a result, for patients with problems in both domains, we do not yet know what sort of treatment is most effective.
Diagnostic and therapeutic challenges
Individuals suffering from both alcohol use disorders and mental illness are likely to encounter one of three types of health care professionals: primary care providers, mental health professionals, or addiction treatment specialists. Unfortunately, primary care providers are unable to devote large amounts of one-on-one time with individual patients. Mental health providers and addiction specialists can offer specialized care for mental illness or alcohol use disorders, respectively, but may lack the expertise to diagnose or treat a comorbid disorder. 16
A number of different treatment permutations exist. The most common model of treatment for individuals suffering both alcohol use disorders and mental illness is sequential treatment. Commonly, the addiction is treat first, and once abstinence is obtained the psychiatric symptoms will be addressed. Alternatively, parallel treatment, in which a patient receives treatment for both addiction and mental illness simultaneously. In both parallel and sequential treatment models, mental health treatment and addiction treatment are typicall provided by separate sets of specialists who may or may not coordinate care. Integrated treatment can address both substance abuse and mental health issues simultaneously, and often involves health care professionals trained to treat both mental illness and addiction. 16
With many individuals with alcohol use disorders suffering co-occurring mental illnesses, and so many possible permutations with regard to therapies, developing firm diagnostic standards for co-morbid mental illness and standardized treatment regimens should be a priority. Diagnostically, physicians face challenges in determining whether heavy alcohol consumption contributes to or arises from a psychiatric disorder, or whether alcohol abuse and mental illness are simply co-morbid conditions.17 Moreover, a number of unique considerations must be addressed in developing a treatment plan for the mentally ill alcohol addict. Many medications have physical side effects when taken with alcohol. Mental illness and alcohol use may impair the patient’s ability to manage medications on his or her own. Psychosocial intervention may aid in treatment of mental illness and provide needed support once alcohol consumption has ceased.17
Current status of dual diagnosis research
Several comprehensive reviews of research studies examining models of treatment for dually diagnosed patients have been published in recent years 18, 19. While all of the studies discussed in this section include participants with alcohol use disorders, many include patients with other substance abuse disorders as well. This is a common theme in the literature surrounding treatment of comorbid mental illness and substance abuse disorders, and represents a potential pitfall of current research strategies.
While a number of approaches have demonstrated promising results in both substance abuse and mental health outcomes, differences in study length, number of sessions provided to participants, and inclusion criteria make it difficult to draw helpful conclusions from these data as a whole.
Individual counseling, consisting of either motivation interviewing or cognitive behavioral therapy, has produced inconsistent results. Several short-term studies (fewer than 12 months) examining the effect of multiple individual counseling sessions on abstinence generally failed to reduce substance use long term.20-22 One study that provided schizophrenic substance abuse patients an integrated treatment program, including cognitive behavioral therapy, motivational interviewing, and family intervention for 9 months found decreased relapse rates at 12 months and decreased negative symptoms at 9 and 18 months.23
Group counseling represents an alternative to individual counseling that may still incorporate cognitive behavioral techniques. While the specifics of group counseling programs studied thus far vary, they all typically provide education and peer support, as well as tools for managing both mental and substance abuse disorders.18 A more recent short-term study of the efficacy of group cognitive behavioral therapy for depressed substance abuse patients showed improved mental health and abstinence, but without any significant difference from control patients.24 Double Trouble in Recovery is a 12 step-based dual-focus mutual aid group designed for adults with dual diagnoses.
Results from this study report improvement in substance abuse outcome but not psychiatric outcome.25 Seeking Safety and Creating Change are two group behavioral therapy models for individuals suffering from both PTSD and substance abuse disorders. Both have shown promise in treating this particular cohort of patients. 26-28
Case management is a set of “intensive, team-based, multidisciplinary, out-reach oriented, clinically coordinated services, usually involving the model assertive community treatment”.18 Eleven studies reviewed by Drake et. al., published between 1991 and 2006, reported inconsistent results in terms of substance abuse and mental health outcomes.18, 29-39 However, several studies reported positive outcomes in other areas, such as decreased hospitalizations, improved financial functioning, and overall improved stability and global functioning.
Studies of integrated versus non-integrated residential treatment program have demonstrated that the integrated residential approach leads to increased abstinence and decreased relapse rates.18, 40-44 Overall, the data suggest that longer-term treatment resulted in better substance abuse outcomes 18, 40. While mental health outcomes were inconsistent, several studies reported fewer psychiatric symptoms in patients who received integrated inpatient care. 41, 44, 45 A more recent study indicated that male veterans with dual diagnoses respond well to inpatient substance abuse treatment, but mental health outcomes tend to be less positive.46
As an alternative to residential treatment programs, intensive outpatient programs typically provide treatment for several hours on several days throughout the week. However, relatively few studies have explored this treatment approach, and results are inconsistent.18, 47
Finally, in addition to various counseling and behavioral treatment techniques, medications may be prescribed to manage alcohol cravings and mental illness symptoms. Despite over two decades of research into pharmacological treatment of alcohol addiction, only three medications are FDA-approved. Disulfiram induces aversion to alcohol by inhibiting alcohol metabolism in such a way that toxic intermediates accumulate in the body and produce unpleasant side effects.48 However, there is a possibility of severe side effects and potentially serious drug interactions, and its therapeutic benefit is inconsistent at best, so it is not widely prescribed.49
Naltrexone, a mu opioid receptor antagonist, likely reduces the urge to drink by interfering with the dopamine reward system.48, 50-52 Among the more serious side effects associated with naltrexone are hepatitis and liver failure.48 Although clinical results demonstrate inconsistency in the outcome of naltrexone treatment, some patients are less likely to engage in heavy drinking and have longer time to relapse. The effect of naltrexone wanes following discontinuation of the drug.54, 55
Finally, the most effective medication currently approved for the treatment of alcohol addiction is acamprosate.48 However, to optimize efficacy, the medication is best prescribed to abstinent patients who have undergone detoxification.56, 57 A number of other compounds, such as nalmefene, topirimate, and ondansetron, have shown promise in the treatment of alcohol use disorders, though none has been approved by the FDA for that use.48, 58
Although naltrexone and acamprosate were developed using animal models, the paucity of new medications coming to market, despite decades of research, is indicative of the shortcomings of current pharmacological development approaches. Moreover, a number of animal models have been developed to try to replicate alcohol addiction and anxiety, depression, stress, or PTSD for the purpose of understanding mechanisms of addiction and mental illness or testing candidate therapeutics 59-66.
These models have major limitations. Unlike humans, laboratory animals are selectively bred for alcohol preference and are trained to consume high doses of ethanol for pre-determined time periods. 59-62 These methods are employed to encourage animals to consume a specific amount of substance in a particular timeframe, a motivation that is distinct from those that drive human consumption of alcohol. In other models of alcoholism, animals do not willingly consume alcohol at all, but are rather injected intraperitoneally or subcutaneously, or receive ethanol via gavage or intubation. 67-69
Moreover, due to species-specific differences in metabolism and scale, the quantity of alcohol consumed by laboratory animals does not easily translate to realistic quantities consumed by adult humans 70. For example, in a model of binge drinking in rats, animals consumed doses of alcohol of 5g/kg body weight just in the first of several doses, administered every 8 hours for four days.64 This is the equivalent of an adult human consuming about 25 drinks in one sitting.71
Depression- or anxiety-like symptoms can be induced in animals by conditioned alcohol dependence or application of chronic stress.59, 72, 73 But the obvious biological and social differences between humans and other animals preclude a meaningful comparison of behavioral stress in laboratory animals to mental illness in humans. 59, 62, 63
While medications can be administered to animals bred to model alcohol addiction, animal data on safety or efficacy may or may not apply to humans, and there is no way to test the combination of medication and psychosocial therapy in these animals, rendering the models not only artificial, but extremely limited as well. Alcoholism is a uniquely human disease, and alcohol abuse disorders combined with various, and potentially overlapping, mental illnesses are too complex to reduce to an animal model.
Optimizing research and treatment strategies
The path forward is clear. There must be a comprehensive approach to treatment based upon data gathered from people with alcohol use disorders. While a number of therapeutic approaches, such as those discussed above, have shown promise in treating patients with alcohol abuse disorders and mental illness, more research is required. Many researchers and health providers seem to have consolidated all substance abuse issues into a single category, and this may contribute to the lack of progress in developing effective treatments for patients with comorbid alcohol abuse disorders and mental illness.
Large, prospective studies examining individual and group therapy methods specifically in patients with alcohol abuse disorders will allow researchers to determine how to address this specific substance abuse disorder, which may require a different approach than other substance abuse issues. Moreover, separating trials by mental illness may prove helpful as well, as different mental illnesses will likely respond well to different types of treatment. A number of unique therapy-delivery strategies, such as individualized assessments or self-delivered computer-based support have shown promise as well, and should be further explored.74, 75
However, both mental illness and addiction are long-term health issues. Determining whether short- or long-term treatment strategies are most effective, and how best to implement such strategies in such as way as to be cost-effective for both patient and provider presents another area of necessary research.
There is room for a great deal of research in the field of comorbid alcohol abuse and mental health issues. Unfortunately, the most limiting factor is the availability of funding for such research. Ultimately, large funding bodies, such as the National Institute of Alcohol Abuse and Alcoholism in the United States, must be pushed to shift their funding strategies to favor these human-based intervention and treatment strategies. Only by conducting human-based interventional trials that can account for the complexity of human biology and behavior will our research produce results that may offer hope to the millions of individuals seeking to overcome the combined hurdles of alcohol abuse and mental illness.
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