In the treatment of addictions, addressing co-occurring disorders is becoming the norm. A holistic view of patient complaints has to include both psychiatry and psychotherapy in conjunction with both traditional and non-traditional forms of recovery counseling.
In the assessment and treatment of co-occurring disorders, there can be a delicate balance in the interactions of the treatment disciplines. Therapists may be resistant to the use of drug therapies, as they do not want their patients to become reliant on medications and to disregard much-needed therapy. Some physicians may not see emotional difficulties as part of the process of healing, but as symptoms to be alleviated through medication. Learning to practice smart pharmacotherapy and smart psychosocial therapy requires an orchestrated, integrated effort, rather than parallel, singular efforts. It is truly a dance, and for the choreography to benefit the patient, the two disciplines must have equal footing.
This article will attempt to provide the reader with a thorough understanding of the interactions between the two disciplines, using co-occurring substance use and anxiety disorders as the context.
Anxiety disorders as a whole are the most common mental illness, with a lifetime prevalence of 29 percent.1,2 Recent studies indicate that approximately 6 percent of adolescents have severe anxiety disorders, based on symptom rating and level of disability. However, there is a large disparity between those who meet criteria for any anxiety disorder and those who seek treatment.3 This places affected youth at two to three times greater risk for substance abuse disorders.4
The most prevalent anxiety disorders are generalized anxiety disorder, social anxiety, panic disorder (with/without agoraphobia), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), phobic disorders, and separation anxiety.2,5,6,7,8
In substance abuse treatment settings, the reporting of anxiety as an ongoing symptom appears to be increasing in the adolescent population. The prevalence of comorbid anxiety in those with substance abuse has been reported to be 20 to 50 percent,9 with an even larger proportion of patients reporting anxiety symptoms that do not meet criteria for any disorder.
A confounding issue is the development of anxiety symptoms while intoxicated or as part of a withdrawal syndrome. Stimulants tend to create anxiety states during intoxication, whereas sedatives, alcohol and opiates tend to produce similar symptoms during withdrawal. Marijuana often is reported to relieve anxiety initially; however, it can induce heightened anxiety states as well as panic attacks with ongoing use.
The question of how best to treat these youths with comorbid illness will become an increasingly pressing one. One of the first assessments should explore whether the individual meets criteria for a distinct anxiety disorder separate from the effects of substance abuse. Detailed history should be obtained from patient and parent in an attempt to delineate the course of illness. It is also imperative to determine the level of disability that the symptoms caused, and to account for variations in development of social skills as well as coping mechanisms to deal with unpleasant affective states.3,4
The therapist and psychiatrist have to work together to make the distinction between anxiety that can be the key to psychotherapy and anxiety that is crippling a person from engaging in psychotherapy.
The primary treatment for anxiety disorders consists of medication and therapy, either alone or in combination. First-line treatment includes cognitive-behavioral therapy (CBT) and psychosocial supports, as well as selective serotonin reuptake inhibitors (SSRIs). Additional medication recommendations are tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), atypical antipsychotics, and beta-blockers.9 Benzodiazepines should be avoided in the young population if at all possible.
The choice as to which medication to use is not entirely arbitrary. Many studies support the use of sertraline for social anxiety, generalized anxiety disorder and PTSD, showing significant improvement vis-à-vis use of placebo.10,11,12 There is also evidence that use of a beta-blocker leads to significantly reduced symptoms.9
A proposed alternative medication strategy accounts for the symptoms of each patient and, ultimately, the side effect profile of each medication. For patients with physical symptoms of anxiety, use of a low-dose beta-blocker scheduled throughout the day can bring significant symptomatic relief, which then allows for ongoing treatment with therapy.9 In those patients who have significant depressive symptoms, an SSRI/serotonin-norepinephrine reuptake inhibitor (SNRI) should be the primary choice. Within this group, fluoxetine, sertraline and venlafaxine tend to be more activating, which can be useful for those with more neuro-vegetative signs of depression. Citalopram, escitalopram and paroxetine tend to be a bit more sedating, which can benefit those in a somewhat more agitated state.