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Problem 6. Comorbidity
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Problem 6. ComorbidityWhat are the most common comorbidities with addiction?
Carrà, G., Bartoli, F., Brambilla, G., Crocamo, C., & Clerici, M. (2015). Comorbid addiction and
major mental illness in Europe: a narrative review. Substance abuse, 75-81.
Introduction
Comorbid alcohol and/or other substance use disorders are highly prevalent in people
suffering from severe mental illness (dual diagnosis). Substance abuse is the most common
comorbid disorder among adults with severe mental illness. Dual diagnosis has a large
increase in prevalence and association with poorer clinical and psychosocial outcomes. The
comorbidity is a risk factor for medication noncompliance, clinical relapse, psychiatric
hospitalization, early readmission after discharge, and risk of overdose, and it is associated
with HIV and hepatitis, aggression, violence, and incarceration. Dual diagnosis is often
underestimated, underdiagnosed, and poorly treated.
Prevalence rates of pure and comorbid drug and alcohol disorders: Europe vs USA
In the EU, for all adults, drug lifetime experience rates range between 0.7% and 35.6% for
cannabis, with an average of 2.8% for cocaine. Problem drug use prevalence data ranges
from 8.2 to 0.3 and 0.22 to 5.68 per 1000 adults. Alcohol (3.4%), opioid (0.1–0.4%), and
cannabis (0.3–1.8%) dependence are among the most prevalent substance-related disorders
in the general population of EU member states. In the USA, prevalence rates are
substantially higher. Alcohol use disorder rates are 4.7% and 3.8% for 12-month and 17.8%
and 12.5% for lifetime (for abuse and dependence). The drug use disorder rates are 1.4%
and 0.6% for 12-month and 7.7% and 2.6% for lifetime (for abuse and dependence). In the
USA and UK being male, unmarried, of a low socioeconomic status, and living in an urban
setting were associated with an increased occurrence of drug dependence.
Research in the Europe showed that the comorbid alcohol and substances rates were lower
than those reported from the USA. The lifetime rate for comorbid dependence on any
substance was 35% in the UK but considerably lower in Germany (21%) and in France (19%).
Also, within the same European country, there may be differences according to service
settings and geographical areas and ethnic composition. In the USA ± 50% of the individuals
who met criteria for a substance use disorder at some time in their life also met criteria for
one or more lifetime mental disorders. There are large variations in dual-diagnosis rates.
Lieb, R. (2015). Epidemiological perspectives on comorbidity between substance use
disorders and other mental disorders. 3-12
Size of the problem in Europe
38.7% of the adult EU population suffer from at least one mental disorder. Anxiety disorders
(14.0%) and major depression (6.9%) are the most frequent mental disorders. Almost 3.4%
are affected by alcohol dependence. 0.1-1.8% of the adult Europeans are affected by drug
dependence (opioid or cannabis dependence).
,Description of comorbidity
Rates for 12-month comorbidity between substance use disorders and other mental
disorders are as follows: Among people who fulfilled DSM-IV diagnostic criteria for alcohol
abuse or alcohol dependence, about half (55.1%) presented this as a “pure” disorder (i.e.,
did not fulfil criteria for any other mental disorder). More than 20% fulfilled diagnostic
criteria for one other mental disorder, 7.8% for two other diagnoses, and 14.4% for three or
even more additional diagnoses. Among people who fulfilled diagnostic criteria for drug
abuse or drug dependence, even a higher proportion were comorbid (total 54.7%). Here,
29.0% fulfilled criteria for one additional diagnosis, 12.9% for two additional diagnoses, and
12.9% for three or more additional diagnoses (within the same 12-month interval).
Among mental disorders, substance use disorders are the less frequently treated disorders.
Only a quarter received a “minimal intervention”. Treatment was offered far more often to
people suffering from other mental disorders. In addition, people with comorbid disorders
tend to report higher healthcare utilization rates than those with pure disorders.
Morisano, D., Babor, T., & Robaina, K. (2014). Co-occurrence of substance use disorders with
other psychiatric disorders: Implications for treatment services. Nad Nordic Studies on
Alcohol and Drugs, 5-25.
Epidemiology of co-occurrence
The co-occurrence of SUDs and other psychiatric disorders is relatively common in the
general population. Individuals with SUDs tend to have higher rates of mental illness than
the reverse, and the percentage rates rise among individuals with illicit drug use disorders.
51.4% of those surveyed with a lifetime SUD also reported a lifetime mental health disorder,
and 50.9% of those with a lifetime history of a mental health disorder also had a lifetime
history of at least one SUD. Adults with a past-year SUD were also more likely to have
serious suicidal thoughts, plans or attempts.
Within Europa, alcohol dependence was commonly and more frequently correlated with
most mood and anxiety disorders than alcohol abuse, although major depression was
associated with both abuse and dependence. In both North American and European
countries, the general population prevalence of co-occurring mood or anxiety disorders and
SUDs in a 12-month period has been estimated at 1-2%; this is likely underestimated. The
most common psychiatric diagnoses among individuals with a co-occurring SUD include
mood, anxiety, and personality disorders.
The NSDUH estimated that in the U.S. the percentage of past-year co-occurring SUD and
other psychiatric disorders was higher among adult males than females (4.1% vs 3.1%). The
percentage of adults with any past-year mental illness who also met criteria for SUD
decreased with age. The 18-25 year-old age bracket had the highest percentage of adults
with co-occurring mental illness and SUD (6.8%).
Differences in adolescent use of substances call for differences in diagnostic criteria.
Potential consequences of untreated or poorly treated co-occurring disorders include overall
poorer functioning and physical health, decreased social functioning, more severe symptoms
of either or both types of disorder, increased risk of being homeless or incarcerated,
disability, and a generally worsened quality of life.
, What different explanations exist for the high comorbidity between addiction and other
mental disorders?
Carrà, G., Bartoli, F., Clerici, M., & El-Guebaly, N. (2015). Psychopathology of dual diagnosis:
new trumpets and old uncertainties. Journal of Psychopathology, 390-399.
Summary
People suffering from severe mental illnesses, such as schizophrenia and major affective
disorders, have high rates of addictive behaviours related to alcohol and illicit substance use.
Comorbidity between mental and substance use disorder is called the ‘dual diagnosis’
phenomenon. It represents an unanswered challenge in terms of pathogenic models,
treatment and long-term clinical management. Dual diagnosis is a complex and
heterogeneous entity and a number of explanatory models of substance use among people
with severe mental disorders have been proposed, aiming to test the ‘self medication’
hypothesis, the potential aetiological role of substance on occurrence of mental disorders,
and the common underlying environmental, genetic and biological factors. Individuals with
dual diagnosis appear to be more often males, with an earlier onset of the mental disorder
and more severe clinical and social outcomes. The co-occurrence of mental and substance
use disorders complicates treatment, management and prognosis of both disorders, but it
remains often unrecognised and undertreated. Mental health and addiction professionals
should accurately assess and evaluate this comorbidity, although aetiological links, temporal
relationships and psychopathological characteristics are still not entirely clear and, probably,
heterogeneous and multifactorial.
Introduction
The term dual diagnosis is used to define the co-occurrence of mental and substance-
related disorders in the same individual. Individuals who suffer from both mental illnesses
and substance use disorders have an increased likelihood of serious clinical consequences
and less favourable long-term outcomes, including risk of hospitalisation, medication
noncompliance, violence, overdose and suicide. The most frequently used substances are
tobacco, alcohol, cannabis and cocaine and rates of substance misuse in people with severe
mental illness are considerably higher compared with healthy individuals. About half of
people suffering from severe mental disorders have a lifetime comorbid substance use
disorder. There are large differences in dual diagnosis rates among people with severe
mental illness, ranging between 20 and 65%.
Psychopathological models and aetiological hypotheses of dual diagnosis
There are no clear and uniformly accepted definitions of comorbidity, and dual diagnosis has
no coherent theoretical framework. Under an atheoretical point of view, most research has
been focused on the analysis of the correlation between addiction and mental disorders,
using disease definitions derived from the standardised diagnostic entities of the DSM and
postulating a diagnostic independence of two distinct and comorbid pathological conditions.
Dual diagnosis is not a simple summa of two clinical entities to think, treat and manage
separately, but represent a single pathological entity where different psychopathological
elements join together, influencing negatively each other. Only a multidimensional
understating may allow to fully understand the phenomenon, but the underlying
mechanisms of the association between mental and substance use disorders are not entirely
clear. A number of explanatory models of substance use among people with severe mental
disorders have been proposed.
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