Comorbidity of Substance Use and Axis I Psychiatric Disorders

Kathleen T. Brady, MD, PhD


Medscape Psychiatry & Mental Health eJournal. 1998;3(4) 

In This Article

Other Common Co-occurring Disorders

The co-occurrence of attention- deficit hyperactivity disorder (ADHD) and psychoactive substance use disorders has recently received much attention. While ADHD used to be thought of as a childhood disorder, recent evidence indicates that approximately 30% of individuals with ADHD continue to have the diagnosis in adulthood. In summarizing data from a number of studies of adults and adolescents with substance use disorders, a mean rate of 23% of subjects with ADHD was found.[75] Investigations of substance use disorders in adults with ADHD have estimated rates of alcohol use disorders to be between 17% and 45% and rates for drug abuse or dependence to be between 9% and 50%.[75]

As with many comorbid conditions, diagnostic issues remain somewhat unclear. Of help in the diagnosis of ADHD is the fact that core ADHD symptoms appear to be developmentally continuous with childhood symptoms. In fact, a longitudinal history of symptoms from childhood must be present to make the diagnosis in an adult. Because attentional problems may be a common occurrence during withdrawal states, assessment of symptoms must be made during a period of abstinence.

Pharmacotherapy plays an important role in the treatment of ADHD (Table I). The psychostimulants are the first line of treatment for uncomplicated ADHD in both children and adults. Because of the abuse potential of the stimulants, it is not clear that these medications are a reasonable choice for the treatment of adults with comorbid ADHD and substance use disorder. Several case studies of stimulant treatment of cocaine-dependent individuals with ADHD indicate therapeutic effects without medication misuse.[76] Clearly, this area warrants further investigation. If a decision is made to use stimulants, the medication use should be closely monitored, with careful evaluation of treatment compliance and substance use status. Other options for pharmacologic treatment include TCAs, clonidine, and bupropion.[77]

Behavioral treatments to improve focus and attention can be helpful in the treatment of childhood ADHD, but are understudied in the treatment of adult ADHD.[77] As with other comorbid conditions, it is important to maximize nonpharmacologic treatment approaches.

Recent studies indicate that substance use disorders and eating disorders commonly co-occur. In a number of studies of substance use disorders in treatment-seeking bulimics, prevalence estimates of substance use disorders averaged 28%.[78] Substance use disorders appear to be less common in individuals with anorexia.

Commonalities between eating disorders and substance use disorders have been noted. These include the loss of control over the use of a substance, preoccupation with an abused substance, the use of a substance to cope with stress and negative feelings, and the secrecy and denial surrounding the behavior.[79] With this in mind, psychotherapeutic techniques that address both disorders clearly need to be developed. Biologic commonalities between these disorders have also been identified that can help guide pharmacologic treatment efforts. The serotonin system is thought to be involved in regulating appetite as well as alcohol consumption. The notion of serotonergic mechanisms underlying all consummatory behaviors has been offered.[14] Selective serotonin drugs have some efficacy in the treatment of bulimia.[80] In the absence of any specific studies addressing pharmacologic treatments in patients with comorbid substance use and eating disorders, SSRIs would be a reasonable first choice when a pharmacologic agent is indicated (Table I).


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