Comorbidity of alcoholism and psychiatric disorders: an overview

Alcohol Research & Health, Spring, 2002 by Ismene L. Petrakis, Gerardo Gonzalez, Robert Rosenheck, John H. Krystal

Antipsychotic Medications. The first line of treatment for patients with schizophrenia or psychotic disorders is antipsychotic, or neuroleptic, medications. Because acute psychosis undermines a person's ability to participate in social, community, and treatment activities, stabilizing these symptoms is usually the first priority in treatment. There are several classes of antipsychotic drugs with differing pharmacology, side effects, and receptor-binding affinity. No controlled studies exist to suggest that one type of antipsychotic is superior in treating the dually diagnosed patient. However, some general principles are known, based on research on the mechanisms of action of the different classes of antipsychotics, the underlying psychology and neurobiology of the disorders, and clinical experience. For example, the newer antipsychotics have been reported to better treat negative symptoms and have fewer movement disorder side effects (e.g., muscle spasms). Because negative symptoms may play a role in the eti ology or maintenance of substance use disorders (i.e., people may use alcohol or other drugs to self-medicate the negative symptoms), these medications may be effective in treating the psychotic symptoms as well as alcohol use in this population. Additionally, this class of medications affects receptors, such as the serotonin receptors, that may play a role in alcohol abuse and dependence. Thus, they may be effective in treating alcohol use disorders as well as psychosis. Supporting these guidelines, a recent pilot study has suggested that clozapine may be effective in reducing symptoms of alcohol use disorders and schizophrenia in dually diagnosed patients (Drake et al. 2000).

Since formal research in this area is limited, a careful individual clinical history and an understanding of the issues specific to that particular population can help guide the choice for the most appropriate antipsychotic medication for each dually diagnosed patient. For example, it is important to consider the medication's potential side effects and the patient's history of medication pliance. It is also important to consider how alcohol may interact with the medication or exacerbate its effects. Highly sedating medications or medications that reduce the seizure threshold in a person concomitantly using alcohol may be problematic. Some patients' psychotic symptoms cannot be stabilized because of medication noncompliance, preventing them from engaging in treatment. For such patients, it may be better to use medications that are injected intramuscularly and released slowly over time (Ziedonis and D'Avanzo 1998).

Psychosocial Treatments for Comorbid Disorders

Recent developments in effective psychotherapy for alcohol use disorders, along with growing recognition that pharmacotherapy alone may not adequately address all the treatment requirements of comorbid patients, has led to the development of specialized psychotherapy for this population. The use of effective psychosocial treatments is particularly important among dually diagnosed patients for four reasons. First, there are some cases where pharmacotherapy may not be recommended (e.g., in alcoholic patients with anxiety disorders for whom taking benzodiazepines may be risky). Second, psychosocial treatments may be effective in treating functional deficits in patients with chronic psychiatric disorders, such as schizophrenia. Third, pharmacologic treatment enhanced with psychosocial approaches is important for patients with poor medication compliance. As mentioned above, even powerful psychopharmacologic treatments, such as disulfiram, are ineffective if patients do not take the medication. And fourth, effectiv e psychosocial treatments are important for patients for whom early abstinence may be associated with a worsening of psychiatric symptoms, such as patients with PTSD who may experience anxiety with the cessation of alcohol use. The following sections review some of the issues surrounding psychotherapeutic treatment for comorbid disorders and the use of 12-step programs by dually diagnosed patients.