Management of comorbidity

Comorbidity of substance use disorders and mental disorders is very common, and there is substantial heterogeneity within subgroups in terms of both their characteristics and the nature of causal relationships between the disorders. Assessment and management strategies need to deal with both the size of the problem across the community and its severe impact in some subgroups, including those with psychosis. At this stage, the research base from which we can derive recommendations is very narrow, but it does offer a foundation for preliminary conclusions. This chapter reviews the current evidence and makes some suggestions for assessment and for both psychological and pharmacological management.

Treatment of comorbidity

Cormorbity means the co-occurrence of one or more diseases or disorders in an individual. The National Comorbity Project aims to highlight this type of comorbity and identify appropriate strategies and policies responses.

Unraveling the complexity of driving while intoxicated: a study into the prevalence of psychiatric and substance abuse comorbidity

Objective Research is beginning to provide an indication of the co-occurring substance abuse and mental health needs for the driving under the influence (DUI) population. This study aimed to examine the extent of such psychiatric problems among a large sample size of DUI offenders entering treatment in Texas. Methods This is a study of 36,373 past year DUI clients and 308,714 non-past year DUI clients admitted to Texas treatment programs between 2005 and 2008. Data were obtained from the State's administrative dataset. Results Analysis indicated that non-past year DUI clients were more likely to present with more severe illicit substance use problems, while past year DUI clients were more likely to have a primary problem with alcohol. Nevertheless, a cannabis use problem was also found to be significantly associated with DUI recidivism in the last year. In regards to mental health status, a major finding was that depression was the most common psychiatric condition reported by DUI clients, including those with more than one DUI offence in the past year. This cohort also reported elevated levels of Bipolar Disorder compared to the general population, and such a diagnosis was also associated with an increased likelihood of not completing treatment. Additionally, female clients were more likely to be diagnosed with mental health problems than males, as well as more likely to be placed on medications at admission and more likely to have problems with methamphetamine, cocaine, and opiates. Conclusions DUI offenders are at an increased risk of experiencing comorbid psychiatric disorders, and thus, corresponding treatment programs need to cater for a range of mental health concerns that are likely to affect recidivism rates.

Psychiatric and substance abuse comorbidity among a large sample of DUI Texas offenders

Research is indicating that individuals who present for DUI treatment may have competing substance abuse and mental health needs. This study aimed to examine the extent of such comorbidity issues among a sample of Texas DUI offenders. Method: Records of 36,372 DUI clients and 308,695 non-DUI clients admitted to Texas treatment programs between 2005 and 2008 were obtained from the State's administrative dataset. The data were analysed to identify the relationship between substance use, psychiatric problems, program completion and recidivism rates. Results: Analysis indicated that while non-DUI clients were more likely to present with more severe illicit substance use problems, DUI clients were more likely to have a primary problem with alcohol. Additionally, a cannabis use problem was also found to be significantly associated with DUI recidivism in the last year. In regards to mental health needs, a major finding was that depression was the most common psychiatric condition reported by DUI clients, including those with more than one DUI offence in the past year. This group were also more at risk of being diagnosed with Bipolar Disorder compared to the general population, and such a diagnosis was also associated with an increased likelihood of not completing treatment. Interestingly, female DUI and non-DUI clients were also more likely to be diagnosed with mental health problems compared to males, as well as more likely to be placed on medications at admission and have problems with methamphetamine, cocaine, and opiates. Conclusion: The findings highlight the complex competing needs of some DUI offenders who enter treatment. The results also suggest that there is a need to utilise mental health and substance abuse screening methods to ensure DUI offenders are directed towards appropriate treatment pathways as well as ensure that such interventions adequately cater for complex substance abuse and psychiatric needs.

Diagnostic Dilemmas in Comorbidity

This high prevalence of comorbid mental health and substance use disorders makes the accurate diagnosis of comorbid disorders an important clinical priority. However, the presence of comorbid disorders creates a number of diagnostic dilemmas, which have hindered our understanding of the comorbid disorders. This chapter discusses these diagnostic dilemmas, including issues with the reliability, validity and clinical utility of current systems of psychiatric nomenclature’s approach to diagnosing comorbid disorders. A number of alternative models for understanding comorbid disorders are briefly discussed, followed by suggestions for how research can improve our understanding of comorbid disorders.

Nurses’ role in caring for people with a comorbidity of mental illness and intellectual disability : A literature review

This article examines literature on the role of the nurse caring for people with a dual disability (DD) of intellectual disability and mental illness. A search of the literature between 2000 and 2010 resulted in a total of 21 articles that met the inclusion criteria. Seven key categories of the role of the nurse were identified: (i) advocacy/health promotion (including working with family); (ii) assessment/case management; (iii) behavioural interventions; (iv) communication; (v) leadership and the nurse’s role within the multidisciplinary team; (vi) functions regarding medication administration; and (vii) safety/risk management. There is a paucity of research about the role of nurses working with people with DD, although a number of opinion-based articles exist. This article identifies a need for the role of the nurse working in DD to be more clearly articulated and for the development of evidence to guide best practice.

Implications of comorbidity for clinical practice

In the past, people with comorbidity have often received inadequate care. The ethical principle of equal access to quality services has important implications for agencies, when combined with knowledge about comorbidity and its management, and about diffusion of innovations across organizations. Comorbidity is common, and often has profound impacts on individuals and families. Tobacco smoking in particular is endemic and affects morbidity, mortality, and functioning. This implies that screening for co-occurring problems should be routine, and that a boutique comorbidity service is impractical. Large numbers mean that universal screening and intervention must be capable of large-scale implementation. Since multiple, closely linked problems are often present, treatments should address these multiple issues, and closely interrelated problems will require well-integrated treatment. Involvement of a single health agency is typically needed. Numbers and severity of problems can blind practitioners and patients to strengths and unaffected areas; these should be assessed and fostered. Better policies and practices for co-occurring disorders will require organizational change. Co-occurring disorders must become core business for organizations and practitioners, so that effective comorbidity practice is rewarded, required skills are present or taught, cues to use the practices are provided, and a culture supporting their application is established.

Polysubstance use in cannabis users referred for treatment: drug use profiles, psychiatric comorbidity and cannabis-related beliefs

Background: Population-based surveys demonstrate cannabis users are more likely to use both illicit and licit substances, compared with non-cannabis users. Few studies have examined the substance use profiles of cannabis users referred for treatment. Co-existing mental health symptoms and underlying cannabis-related beliefs associated with these profiles remains unexplored. Methods: Comprehensive drug use and dependence severity (Severity of Dependence Scale-Cannabis) data were collected on a sample of 826 cannabis users referred for treatment. Patients completed the General Health Questionnaire, Cannabis Expectancy Questionnaire, Cannabis Refusal Self-Efficacy Questionnaire, and Positive Symptoms and Manic-Excitement subscales of the Brief Psychiatric Rating Scale. Latent class analysis was performed on last month use of drugs to identify patterns of multiple drug use. Mental health comorbidity and cannabis beliefs were examined by identified drug use pattern. Results: A three-class solution provided the best fit to the data: (1) cannabis and tobacco users (n = 176), (2) cannabis, tobacco, and alcohol users (n = 498), and (3) wide-ranging sub- stance users (n = 132). Wide-ranging substance users (3) reported higher levels of cannabis dependence severity, negative cannabis expectancies, lower opportunistic, and emotional relief self-efficacy, higher levels of depression and anxiety and higher manic-excitement and positive psychotic symptoms. Conclusion: In a sample of cannabis users referred for treatment, wide-ranging substance use was associated with elevated risk on measures of cannabis dependence, co-morbid psychopathology, and dysfunctional cannabis cognitions. These findings have implications for cognitive-behavioral assessment and treatment.

Common genetic influences underlie comorbidity of migraine and endometriosis

We examined the co-occurrence of migraine and endometriosis within the largest known collection of families containing multiple women with surgically confirmed endometriosis and in an independent sample of 815 monozygotic and 457 dizygotic female twin pairs. Within the endometriosis families, a significantly increased risk of migrainous headache was observed in women with endometriosis compared to women without endometriosis (odds ratio [OR] 1.57, 95% confidence interval [CI]: 1.12-2.21, P=0.009). Bivariate heritability analyses indicated no evidence for common environmental factors influencing either migraine or endometriosis but significant genetic components for both traits, with heritability estimates of 69 and 49%, respectively. Importantly, a significant additive genetic correlation (r(G) = 0.27, 95% CI: 0.06-0.47) and bivariate heritability (h(2)=0.17, 95% CI: 0.08-0.27) was observed between migraine and endometriosis. Controlling for the personality trait neuroticism made little impact on this association. These results confirm the previously reported comorbidity between migraine and endometriosis and indicate common genetic influences completely explain their co-occurrence within individuals. Given pharmacological treatments for endometriosis typically target hormonal pathways and a number of findings provide support for a relationship between hormonal variations and migraine, hormone-related genes and pathways are highly plausible candidates for both migraine and endometriosis. Therefore, taking into account the status of both migraine and endometriosis may provide a novel opportunity to identify the genes underlying them. Finally, we propose that the analysis of such genetically correlated comorbid traits can increase power to detect genetic risk loci through the use of more specific, homogenous and heritable phenotypes.

Depression, Anxiety, Psychiatric Comorbidity and Dimensions of Temperament and Personality

This study is part of the Mood Disorders Project conducted by the Department of Mental Health and Alcohol Research, National Public Health Institute, and consists of a general population survey sample and a major depressive disorder (MDD) patient cohort from Vantaa Depression Study (VDS). The general population survey study was conducted in 2003 in the cities of Espoo and Vantaa. The VDS is a collaborative depression research project between the Department of Mental Health and Alcohol Research of the National Public Health Institute and the Department of Psychiatry of the Peijas Medical Care District (PMCD) beginning in 1997. It is a prospective, naturalistic cohort study of 269 secondary-level care psychiatric out- and inpatients with a new episode of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) MDD. In the general population survey study, a total of 900 participants (300 from Espoo, 600 from Vantaa) aged 20 70 years were randomly drawn from the Population Register Centre in Finland. A self-report booklet, including the Eysenck Personality Inventory (EPI), the Temperament and Character Inventory Revised (TCI-R), the Beck Depression Inventory and the Beck Anxiety Inventory was mailed to all subjects. Altogether 441 participants responded (94 returned only the shortened version without TCI-R) and gave their informed consent. VDS involved screening all patients aged 20-60 years (n=806) in the PMCD for a possible new episode of DSM-IV MDD. 542 consenting patients were interviewed with a semi-structured interview (the WHO Schedules for Clinical Assessment in Neuropsychiatry, version 2.0). 269 patients with a current DSM-IV MDD were included in the study and further interviewed with semi-structured interviews to assess all other axis I and II psychiatric diagnoses. Exclusion criteria were DSM-IV bipolar I and II, schizoaffective disorder, schizophrenia or another psychosis, organic and substance-induced mood disorders. In the present study are included those 193 (139 females, 54 males) individuals who could be followed up at both 6 and 18 months, and their depression had remained unipolar. Personality was investigated with the EPI. Personality dimensions associated not only to the symptoms of depression, but also to the symptoms of anxiety among general population and in depressive patients, as well as to comorbid disorders in MDD patients, supporting the dimensional view of depression and anxiety. Among the general population High Harm Avoidance and low Self-Directedness associated moderately, whereas low extraversion and high neuroticism strongly with the depressive and anxiety symptoms. The personality dimensions, especially high Harm Avoidance, low Self-Directedness and high neuroticism were also somewhat predictive of self-reported use of health care services for psychiatric reasons, and lifetime mental disorder. Moreover, high Harm Avoidance associated with a family history of mental disorder. In depressive patients, neuroticism scores were found to decline markedly and extraversion scores to increase somewhat with recovery. The predictive value of the changes in symptoms of depression and anxiety in explaining follow-up neuroticism was about 1/3 of that of baseline neuroticism. In contrast to neuroticism, the scores of extraversion showed no dependence on the symptoms of anxiety, and the change in the symptoms of depression explained only 1/20 of the follow-up extraversion compared with baseline extraversion. No evidence was found of the scar effect during a one-year follow-up period. Finally, even after controlling for symptoms of both depression and anxiety, depressive patients had a somewhat higher level of neuroticism (odds ratio 1.11, p=0.001) and a slightly lower level of extraversion (odds ratio 0.92, p=0.003) than subjects in the general population. Among MDD patients, a positive dose-exposure relationship appeared to exist between neuroticism and prevalence and number of comorbid axis I and II disorders. A negative relationship existed between level of extraversion and prevalence of comorbid social phobia and cluster C personality disorders. Personality dimensions are associated with the symptoms of depression and anxiety. Futhermore these findings support the hypothesis that high neuroticism and somewhat low extraversion might be vulnerability factors for MDD, and that high neuroticism and low extraversion predispose to comorbid axis I and II disorders among patients with MDD.