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October 5, 2019

Substance abuse and mental illness

Reuel S. Amdur

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Mental Illness and substance abuse: which comes first? This was the question posed at an address at a Royal Ottawa Hospital presentation on September 19. The presenters were two Royal Ottawa psychologists, Drs. Isabelle Ares and Suzanne Bell.

The answer to the question posed was definitive: It depends.  Substance abuse—alcohol and/or drugs—can lead to mental illness.  Take the instance of someone who has the propensity to become schizophrenic.  Smoking marihuana or binge-drinking could trigger the illness.  On the other hand, someone who is mentally ill may indulge in substance abuse in order to self-medicate.  A person with depression might drink, perhaps to forget, but alcohol is a depressant, so it will soon make the problem worse.

It is also possible that one factor may be implicated in development of both a mental illness and substance abuse.  Ares gave the example of someone from a disordered family.  In any case, people suffering from mental illness are likely as well to abuse substances, and vice versa.

Given this understanding of the situation, what are the implications for treatment?  Here again, we come back to the same conclusion: It depends.  One size does not fit all.  And, frankly, clinicians have their own preferred methodologies.

One approach to treatment is pharmaceutical.  Perhaps best known these days are use of methadone to treat opioid addiction, and antipsychotic medications. Dr. Bell listed a variety of psychological approaches, but she also stressed the importance of life circumstances.  For example, security of housing, income adequacy, and social supports are all important. She listed six therapeutic approaches: motivational interviewing, harm reduction, cognitive behavioral therapy, dialectical behavior therapy, family therapy, and contingency management.

Motivational interviewing focuses the patient on conflicting goals and helps him on working toward the healthier ones.  Harm reduction aims to lessen a problem behavior, for example, the provision of controlled amounts of alcohol to avoid massive alcohol abuse.

In cognitive behavioral therapy (CBT), the therapist deals with distorted thought patterns, beliefs, and attitudes and helps the patient to improve emotional controls and develop coping strategies.  Dialectical behavior therapy is a form of CBT.

The startling thing about this list is that there is no mention of psychoanalytically-based treatment.  This absence underlines the growing movement in treatment toward more behavioral approaches as opposed to analytical ones, less focus on underlying causes, more focus on the here-and-now, less on the past.

When it comes to treatment for concurrent disorders, Dr. Bell listed three approaches: integrated treatment, parallel treatment, and sequential treatment.  In integrated treatment, abuse and mental illness are treated together, at the same time.  Parallel treatment has the patient visiting two programs at the same time, one for mental illness and the other for substance abuse.  If treatment is sequential, treatment for one condition follows with treatment of the other.  “Integrated treatment,” said Bell, “is the gold standard.” 

Two cautions remain: We must not consider that every person who consumes a substance is an abuser. That depends on factors such as quantity, frequency, and degree of compulsion.  As for the other matter to keep in mind, in all likelihood treatment is not a one-off.  People may need to have help with their difficulties if not continuously then at least from time to time.

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