In 2013, almost one in five American adults, or 18.5 percent of the population over the age of 18, had a mental illness in the past year, and 4.2 percent had a serious mental illness, according to the most current National Survey on Drug Use and Health.
Mental illness affects a person’s mood, thinking, feelings, and the ability to relate to others, disrupting everyday life functions. Many factors are thought to play a role in the development of a mental illness, from genetic predispositions to environmental aspects. The National Institute on Mental Illness (NAMI) reports that 75 percent of all mental health conditions are present by age 24. Mental health disorders are highly treatable, and positive outcomes increase with early intervention.
Substance use disorder is also considered a mental health disorder by the American Psychiatric Association. It is classified as a chronic and relapsing brain disease. Approximately 22.7 million people in the United States over the age of 12 needed specialized treatment for an alcohol or illicit drug abuse problem in 2013, according to the NSDUH.
Substance use disorder commonly co-occurs with mental illness, and NAMI estimates that half of all people suffering from a serious mental illness and one-third of those suffering from any mental illness also have issues with substance abuse.
Substance abuse may serve as a form of self-medication or temporary relief from mental illness symptoms, although it merely increases treatment complications and health concerns, actually making symptoms worse in the long run. Substance abuse may further heighten or initiate mental illness symptoms, and half of drug abusers as well as one-third of alcohol abusers also suffer from mental illness.
When mental illness and a substance abuse disorder co-occur, it is considered a dual diagnosis. Teams of medical professionals will need to work together to provide integrated and simultaneous treatment. Often, treatment plans for co-occurring disorders include the use of medications in order to promote recovery. These medications should be managed and closely monitored by health care professionals.
Schizophrenia affects one percent of the population, as estimated by NIMH, and it can be a severe and disabling disorder, although medications can help manage the agitation, hallucinations, and delusions. Antipsychotic and atypical antipsychotic medications are often used to successfully decrease symptoms of schizophrenia.
These medications include:
As with any medication or drug, side effects may occur and can include drowsiness, dizziness, restlessness, rapid heart rate, muscle spasms, rashes, menstrual issues in women, blurred vision, rigidity, and sensitivity to the sun. Side effects may increase with substance abuse also. The most common substance use disorder to co-occur with schizophrenia is nicotine dependence related to smoking, and those suffering from schizophrenia are three times more likely than their peers to smoke, as reported in PsychCentral.
Smoking is liable to decrease the effectiveness of atypical antipsychotic medications as well. Clozapine is an atypical antipsychotic medication that has been shown to be successful reducing both psychotic symptoms of schizophrenia as well as substance abuse and smoking, as published in Current Opinions in Psychiatry.
Research also shows similar positive results in the medication quetiapine in those with a dual diagnosis, particularly those who abused cocaine, alcohol, or amphetamines. Atypical antipsychotic medications may also be used to treat symptoms of bipolar disorder.
Between 2005 and 2008, antidepressant medications were the third most commonly taken medication in the United States. Today, one in ten Americans age 12 and older take antidepressants, as reported by the Centers for Disease Control and Prevention (CDC). Antidepressant medications are commonly prescribed to treat depression, mood disorders, and anxiety disorders. Depression is classified by a pervasive sadness that affects daily life.
Many times, depression may go undiagnosed or untreated, and substance abuse is used in an attempt to numb the pain. Nearly one-third of those suffering from major depressive disorder may also suffer from substance abuse disorder. The NSDUH reported that in 2013 approximately 3.9 percent of American adults had serious suicidal thoughts in the past year as well.
Depressive symptoms can be successfully managed with the proper medications. The disorder is thought to affect the balance of the brain’s natural neurotransmitters responsible for feelings of pleasure, and antidepressant medications seek to restore this balance. Substance abuse also makes chemical changes in the brain’s reward pathways, and antidepressants are often used during recovery.
The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs), which include medications like Prozac, Celexa, Zoloft, Lexapro and Paxil. Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as Cymbalta and Effexor are also popular, as is Wellbutrin, which affects dopamine production and absorption.
Older medications included tricyclics like Norpramin and Tofranil and monoamine oxidase inhibitors (MAOIs) such as Nardil, Emsam, Parnate and Marplan. MAOIs interact with certain foods with potential life-threatening complications, and tricyclics may cause an unsafe drop in blood pressure upon standing, so these medications are usually only used if SSRIs or other antidepressants prove ineffective.
Unlike older antidepressant medications, SSRIs do not artificially produce euphoria; instead, they work to block the absorption of the neurotransmitters your brain produces naturally that increase happiness and bolster moods. SSRIs, therefore, likely have a lower rate of abuse and addiction potential than other pharmaceuticals, although some researchers argue that the presence of withdrawal symptoms upon discontinuation may indeed indicate a dependence or addiction.
Other side effects of antidepressant medications include:
- Sexual dysfunction
- Bladder issues
- Dry mouth
- Blurred vision
Many of these side effects will decrease over time, although mixing these medications with other drugs or alcohol may heighten the risk factors. It is also important not to stop taking antidepressants without the permission and monitoring of your doctor. SSRIs discontinuation syndrome can occur if you stop taking these medications suddenly, and it may produce flu-like symptoms and an alteration in touch sensations.
Anxiety disorders affect 18 percent of the American population and are the most common mental illness in the country, as reported by the Anxiety and Depression Association of America (ADAA).
Anxiety disorders and their prevalence in the United States, as published by ADAA, are as follows:
- Phobias: 8.7 percent of the population
- Social anxiety disorder: 6.8 percent of the population
- Generalized anxiety disorder: 3.1 percent of the population
- Panic disorder: 2.7 percent of the population
- Post-traumatic stress disorder (PTSD): 3.5 percent of the population
- Obsessive-compulsive disorder: 1 percent of the population
The ADAA further estimates that around half of those diagnosed with depression or a depressive disorder also suffer from an anxiety disorder as well. SSRIs, SRNIs and tricyclic antidepressants are often used to treat anxiety disorders, as are anti-anxiety medications including benzodiazepines and beta blockers like propranolol, which is more commonly used for treating heart conditions and high blood pressure, but may also be effective on physical anxiety symptoms like sweating and trembling.
Beta blockers may make symptoms of asthma or diabetes worse and therefore are not recommended for those patients. Other side effects of beta blockers may include cold hands, weakness, dizziness and fatigue.
Buspar is another anti-anxiety medication useful for controlling the rapid heart rate, trouble sleeping, irritability, and sweating indicative of anxiety disorders. It may take up to two weeks to take effect. Side effects include nervousness, lightheadedness, nausea, headaches, trouble sleeping and excitability.
Benzodiazepine medications such as Klonopin, Ativan, Valium and Xanax may relieve anxiety symptoms faster than most antidepressants, beta blockers, or Buspar; however, they are only meant for short-term treatment, as users may develop a tolerance requiring higher doses in order to be effective. The problem with increasing dosage is that it may lead to dependence on the medication and then to addiction.
Benzodiazepines are psychoactive central nervous system depressants that produce sedative, calming, anticonvulsant, and relaxing effects, and they are some of the most widely prescribed medications in the United States, according to Medical News Today. These medications are beneficial in treating insomnia and seizures as well as anxiety. Benzodiazepine medications increase the production of gamma-aminobutyric acid (GABA), one of the brain’s neurotransmitters that helps to reduce anxiety and stress.
Benzos are considered relatively safe when used as medically directed and for a short period of time. Side effects of benzodiazepines include dizziness, drowsiness, confusion, shaking, depressive thoughts, vision problems, headaches, impaired coordination, nightmares, and grogginess. Benzodiazepines may also increase the risks for developing Alzheimer’s disease when used chronically in patients over the age of 65, a study published by the British Medical Journal found.
Benzodiazepines are often abused, however, and use should be supervised and continuously assessed in those with a dual diagnosis. Benzodiazepines are commonly abused with other substances, including illicit drugs and/or alcohol. Mixing these substances, particularly with other central nervous system depressants, may have potentially life-threatening consequences. The CDC reported that drug overdose was the leading cause of injury death in 2013, and 30.6 percent of all pharmaceutical drug overdoses involved benzodiazepines.
Benzodiazepine withdrawal may also be dangerous and should not be attempted without proper medical supervision. Dual diagnosis treatment includes therapies and behavioral modification in addition to closely monitored medications in order to successfully treat anxiety disorders.
Bipolar disorder, characterized by episodes of mania and depression, as well as borderline personality disorder, wherein troubles with interpersonal relationships, instability of emotions, and self-image are symptoms, may be managed with mood stabilizers. This class of medications works best on the episodes of mania and mood regulation.
Lithium was the first mood stabilizer approved by the U.S. Food and Drug Administration, or FDA, and continues to be used today. Lithium is estimated to improve symptoms over 50 percent of the time, according to PsychCentral. Lithium may take up to three weeks to reduce manic symptoms and six weeks for depressive symptoms.
Use of the drug needs to be closely and regularly monitored through a renal function, or blood test, due to the way it is processed and retained in the kidneys. Thyroid checks also need to be performed as lithium can affect thyroid performance also.
Other potential side effects of lithium use include:
- Excessive thirst
- Frequent urination
- Impaired coordination
- Slurred speech
- Irregular heart rate
- Rash or itching
- Changes in vision
Typically, the treatment of bipolar disorder requires the use of another adjunct medication, such as an antidepressant, in order to manage both the high and low mood swings. Anticonvulsant medications have also proven to be effective when used as mood stabilizers and include medications, such as Depakote, Tegretol, Lamictal, Trileptal and the antiepileptic drug Topamax.
Fluctuations in weight are common with these medications, and loss of appetite may also be a side effect, in addition to stomach pain, nausea and vomiting. Depakote may be particularly useful in stabilizing moods for those also suffering from substance abuse.
Physical stability is the initial goal and often the first step in substance abuse treatment, and it is especially important for those also suffering from a mental health disorder. The purging of toxins from the body is called detox, which often includes the use of medications to ensure safety and help manage potential withdrawal symptoms. Medical detox is performed in a specialized facility under constant medical supervision.
Opioid withdrawal can be extremely uncomfortable, and the use of buprenorphine medications such as Suboxone and Subutex can reduce discomfort. Buprenorphine is a long-acting partial opioid agonist that binds to opioid receptor sites in the brain, dispelling potential withdrawal symptoms without producing the same high as more potent opioids.
Naloxone is an opioid antagonist that affectively blocks opioid receptor sites, preventing the interaction of other opioids if and when they are introduced. Naloxone is added to Suboxone along with buprenorphine, and it is often used during substance abuse treatment in order to prevent relapse. Naloxone is also sometimes used to deter alcoholics from relapsing. Dual diagnosis treatment requires simultaneous and integrated care by prescribing physicians, counselors, and therapists to ensure medications will be safe and useful in treating both disorders.
Medications are beneficial in treating mental health disorders and managing symptoms, and many are safe and effective for those suffering from a co-occurring substance disorder as well. Mental health professionals agree that typically the most successful treatment plans will include psychotherapy as well as medications in order to promote long-term recovery and management of symptoms. Those battling a substance abuse disorder benefit from peer support and 12-Step groups as well as family, individual, and group counseling sessions.
Learning new and healthy ways to cope with external and internal stressors also goes a long way toward a prolonged recovery. FRN treatment facilities are specially equipped to provide comprehensive evidence-based care models for the treatment of co-occurring disorders. Professional staff members are highly trained to work together to achieve positive and lasting results. A detailed assessment is the first step in determining which treatment model will provide you or your loved one with the best possible continuum of care.
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David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.