Mood Disorders and Substance Use Disorders

Introduction

Mood disorders and substance use disorders (SUDs) can complicate one another. This essay addresses SUDs and some of these complications.

What is a substance use disorder?

Many people have a misconception about what constitutes a substance use disorder. For example, some believe that people are alcoholics if they drink over a certain amount per day, if they "have to have" alcohol daily, or only if they experience withdrawal symptoms on stopping. Similarly, some equate any use of an illegal substance with an SUD or view heavy cigarette smoking as simply a bad habit.

SUDs are defined by the effect of the alcohol or drug use on a person's life, rather than on any arbitrary amount or frequency of use. Two levels are distinguished: "abuse" and the more severe "dependence." Actual diagnosis is made more complicated if use is heavy only at specific times, such as at college, in war, or when in personal distress. Additionally, because SUDs are chronic conditions that evolve over the course of a person's life, use patterns fluctuate and at times can appear normal.

Dependence

People who have alcohol or drug dependence — the more severe type of SUD — usually have one or two lesser-known symptoms underlying their more visible ones. These less-visible symptoms tend to intensify over time and have been documented most clearly with alcohol use:

Abnormally high tolerance
People with alcohol dependence must drink more than normal people in order to feel the effect of alcohol. Put another way, they can drink much more than normal people without appearing intoxicated. They can tolerate blood levels of alcohol that would be lethal to a normal person. This trait appears to be inherited, occurring in the children of 40% of alcoholic people and in the children of less than 10% of nonalcoholic people. Prospective studies are demonstrating that this trait, which is present before the onset of alcoholism, is a predictor for later development of the disorder. Because this "wooden leg" trait is positively valued in our society, these people - who won the drinking contests in college — often do not understand that it is a risk factor for later drinking problems.

Reduced internal control
In normal people, the desire for more alcohol decreases as the drinking proceeds. The result is that the person stops drinking without the need for an active effort. For an alcoholic person, however, the desire for alcohol increases as the drinking proceeds. Psychological energy must be exerted in order for the person to stop drinking. The result is that drinking becomes unpredictable, and the person may drink excessively in particularly inappropriate settings. Even when the person stops and appears to be drinking "normally," the invisible effort often required to do so differentiates the person's behavior from normal drinking. If only one drink will be possible, some alcoholic people will not take it, because of the discomfort of stopping there. In order to avoid getting into trouble as this symptom intensifies, alcoholic people will make up rules for their drinking. These usually work temporarily but become less effective over time as exceptions are made and the rules are ultimately amended.

SUDs and mood disorders

Caffeine, alcohol, and nicotine are the most common mood-altering substances used in our society. Caffeine is an infrequent cause of problems.

Alcohol problems are common in people with bipolar disorders, especially in people with bipolar I disorder who have full-blown manic episodes. The effect of alcohol on people's feelings and behavior is complex. It can have a transient activating influence on behavior, probably because it loosens inhibitions. Alcohol is classified as a central nervous system "depressant" because of its suppressant effect on vital functions such as respiration, which can be severe enough to be lethal. Alcoholic drinking can cause a secondary depression that clears spontaneously over one to four weeks when the drinking stops. Some people with primary depression, nevertheless, turn to alcohol because of its ability to numb or distract from the pain of depression. Alcoholic drinking appears to reduce the effect of antidepressant medications. Tobacco use remains high in individuals with depression. Nicotine does not appear to have an antidepressant effect but can relieve stress and help with appetite control. Even if people are not depressed at the time that they quit, people with a history of depression have a harder time quitting smoking than people without such a history. An infrequent but dramatic phenomenon is the sudden onset of severe depression in a few individuals who attempt to quit smoking.

The incidence of stimulant, opioid, and marijuana use by people with mood disorders is much lower than the incidence of alcohol and nicotine use. From another perspective, however, people coming for treatment for dependence on such drugs have mood disorders at the same or higher frequency as people coming for treatment for alcohol use.

Treatment

When patients have both a primary mood disorder and a primary substance-use disorder, and only one is treated, the untreated problem does not spontaneously improve. The optimal treatment strategy, therefore, is to address both problems simultaneously. Sequential treatment is next best.

The cornerstone of treatment of SUDs is abstinence from all addictive substances. Many people with SUDs regard this as too extreme an approach and attempt to find ways to moderate their use or switch to another substance rather than abstain entirely. Such alternatives rarely succeed over time. Benzodiazepine tranquilizers and prescription narcotics, which may be safe for non-SUD patients, are to be avoided as well. Successful treatment results in what is termed "recovery" rather than "cure," because a return to limited use is never regarded as safe, no matter how long the person has been abstinent.

Detoxification is a necessary first step for a small number of patients with alcohol problems and most patients with opioid problems. In the past, hospitalization was usually necessary, but now detoxification can usually be accomplished in an ambulatory setting.

Most people with SUDs can stop using temporarily on their own, but remaining abstinent without assistance is much more difficult. The most effective programs are based on specialized, structured groups — rather than on traditional office-based individual therapy. The treatment strategy begins with an intensive schedule in which the person abstains from substances from the onset of treatment. Originally, these programs were located only in residential facilities. Although residential programs are still available, the majority of treatment now occurs in ambulatory "intensive outpatient" and psychiatric partial hospitalization settings. Family involvement is an important component. The time frame for this first phase ranges from three to twelve weeks. Because SUDs are chronic conditions, follow-up treatment is important for up to one to two years.

Many people experience a mild euphoria, known as a "pink cloud," during the first weeks or months of recovery, as their secondary depression dissipates. People with primary depressions are often disappointed not to have this experience. This disappointment can add to a sense of being different from other people with SUDs and can lead to relapse. Persistent abstinence, however, plus treatment for the depression, can achieve the same quality of recovery reached by patients without mood disorders.

Medications

Medications can play an important role in enhancing recovery and are compatible with medications given for mood disorders. Tranquilizers, such as Librium (chlordiazepoxide) for alcohol withdrawal, and narcotics, such as methadone and buprenorphine (suboxone) for opioid withdrawal, make detoxification a safe and tolerable procedure.

Maintenance medications are particularly useful in combination with therapy. They are less effective when used alone. For alcohol, Antabuse (disulfiram) has been used since the 1940s to help people resist alcohol. It has no effect unless the person drinks alcohol; then it creates physical discomfort by interfering with the breakdown of alcohol by the liver. Revia (naltrexone) can eliminate the craving for alcohol, as well as reducing the high, so that a single drink of alcohol is less likely to lead to a binge. Campral (acamprosate), a medication used for many years in Europe to decrease alcoholic relapses, became available in the U.S. in January of 2005.

For opioid treatment, long-acting narcotics such as methadone can stabilize a person's life. Although methadone is politically controversial, studies support its considerable superiority in effectiveness over abstinence-based programs, particularly for heroin problems. Suboxone (buprenorphine) is a newly approved narcotic that is safer and less sedating than methadone and is proving to be a valuable tool in treatment. Restrictions exist on physicians' ability to prescribe these medications. Revia (naltrexone) can completely block the euphoric effect of opioid drugs, but treatment results have been disappointing because patients are reluctant to continue taking the medication.

For tobacco dependence, nicotine delivery vehicles such as patches and gum can reduce withdrawal symptoms. These delivery systems can be used in combination with Zyban or Wellbutrin (bupropion) and can reduce craving and diminish the positive effect of nicotine. Many insurance companies will not pay for this medication as a treatment for tobacco dependence, but a depressed person could use this medication for both its antidepressant effects and its antitobacco benefits.

Many medications have been tried for the treatment of cocaine and amphetamine problems, but most clinicians have not found them consistently useful.

Support Groups

Recovery from SUDs can be achieved through involvement solely in professional treatment or solely in support groups. People who combine both, however, generally have a better prognosis and a better quality of sobriety. The best-known and most available support groups are the 12-Step Fellowship Groups, named for the 12 steps that are fundamental to the groups' approach to recovery. Alcoholics Anonymous, or AA, is the largest and oldest of these organizations and has been a model for others, such as Narcotics Anonymous and Cocaine Anonymous.

AA as an organization has always worked closely with psychiatric advisors. Its cofounder, Bill Wilson, suffered with severe depressions for many years despite his recovery from alcohol use and was very interested in early experiments with medication. Current AA literature specifically supports the use of nonaddictive prescribed medication for psychological problems that may interfere with recovery. Some AA members, however, are not aware of this policy and sometimes pressure other AA members to stop taking antidepressant and mood-stabilizing medication. Such members believe that these "mood-altering substances" are addictive in the same manner as benzodiazepines or narcotics and therefore jeopardize recovery. These ideas can, unfortunately, result in the target person's either stopping the prescribed medication or withdrawing from the support group. Such pressure is becoming less common as AA members become more sophisticated and the evidence becomes clear over time that recovery is not endangered by these medications.

Specialized AA groups are common, such as those for women, young adults, gays, medical professionals, and lawyers. Accordingly, groups for people with other psychiatric diagnoses ("double trouble" groups) exist in some areas and can be especially supportive for people with mood disorders.

People who object to the spiritual focus of the 12-step groups are sometimes more comfortable with the cognitive emphasis of Smart Recovery or Women for Sobriety. These groups can, however, be harder to locate and do not have the longevity of the 12-step programs.

Relapses

Some people are able to remain continuously abstinent on their first attempt. Many, however, return to using alcohol or drugs even after an enthusiastic and committed beginning. Relapse usually occurs during periods of well-being — when people feel so good that they believe they are cured, rather than merely recovered. A minority of relapses occur during periods of stress or physical or psychological pain, when the substance use serves as relief or a distraction. For people with bipolar disorders, a particularly high-risk time is during a period of hypomania (relatively mild mania), when they may stop taking their mood-stabilizer and resume drinking or drugging, or vice versa.

During a relapse, people often become discouraged and ashamed, believing that they have made no progress. This can become a self-fulfilling prophecy, leading to permanent deterioration. It is, therefore, important not to get caught up in this whirlpool and to be aware that many people survive relapses and go on to establish sustained sobriety.

Conclusion

Effective treatment exists for both SUDs and mood disorders. Because the prognosis for recovery from SUDs is reduced when another psychiatric diagnosis exists, getting appropriate treatment for both disorders is essential.

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