Co-occurring Psychiatric Disorders

The relationship between substance use disorders and other psychiatric disorders is complex and bidirectional, i.e. most psychiatric disorders increase the likelihood of a substance use disorder and many psychiatric symptoms can be caused by the use of addictive substances.

Bipolar disorder has a 50 % comorbidity with addictive disorders, i.e. 50% of persons with bipolar disorder have substance use disorder, (40% of bipolar II patients and 60% of bipolar I patients.) Proper treatment of a co-ocurring psychiatric disorder significantly improves the rate of recovery from a substance use disorder.

However, most psychiatric symptoms in persons with active substance use are caused by the substance use itself. Depression, anxiety, insomnia and attentional problems are the most common symptoms caused by addictive substances. Other forms of cognitive impairment and manic and psychotic states can also be seen. Addictive substances can also temporarily improve some of these symptoms but in the long run will make them worse, leading to a vicious cycle of self-medication with diminishing results and worsening symptoms.

The presence of significant psychiatric symptomatology preceding the onset of substance use or during periods of sustained abstinence as well as family history are important clues to a co-ocurring psychiatric disorder. Rapid improvement of symptoms with detoxification is an important clue that the symptoms are substance induced. However, substance-induced psychiatric symptoms (referred to as post-acute withdrawal) often persist beyond the detoxification period well into the first year of sobriety.

Causation in many cases is not clear. Fortunately, it is not usually necessary to be fully certain of causation before starting treatment. We have many safe, effective, non-addictive psychiatric medications that can help whether the distress is caused by a co-ocurring disorder or the substance use itself. Thirty years ago it was common practice not to treat comorbid depression until patients had achieved 4-6 weeks of sobriety. Since then, evidence has developed that treatment of comorbid depression in newly detoxified patients improves outcome whether the depression is substance induced or not. Additionally, our multidisciplinary staff are trained and skilled in a variety of non-pharmacologic approaches, including cognitive-behavioral therapies, acupuncture, and dialectical behavior therapy, which also help patients dealing with emotional distress.

In general, we avoid the use of addictive medications in the psychiatric treatment of our patients at CeDAR. Rare exceptions are made where there is strong evidence for a co-occurring disorder and non-addictive pharmacologic and non-pharmacologic alternatives have been exhausted.

Of course, we do use some addictive medications for the primary treatment of withdrawal syndromes—benzodiazepines or phenobarbital for alcohol withdrawal, phenobarbital for sedative-hypnotic withdrawal, and buprenorphine for opiate withdrawal. And in some cases we use buprenorphine for ongoing treatment of opiate dependence beyond the detoxification phase (see section on medication-assisted treatment for opiate dependence.)

Development and maintenance of sobriety and addiction psychiatry follow-up are essential for the optimal outcome of all psychiatric comorbidity. We discharge all patients with a detailed recovery aftercare plan specific to the individual case. For patients discharged on psychiatric medications we refer patients whenever possible to trained and certified addiction psychiatrist. The growth of telepsychiatry is making this more feasible and convenient in many remote underserved areas. How long to stay on medication is a decision best made in conjunction with an addiction psychiatrist familiar with the individual case and we recommend close follow-up with an addiction psychiatrist in the period after a patient tapers off psychiatric medication.