Addiction and Mental Illness

“Have you drunk alcohol in the past 24 hours? Are you addicted to drugs? Do you want to kill yourself?” These were the questions asked of Eric Walton by the officer who booked him at the local police station for violently attacking his father. Eric was 11 years old.

His parents viewed jail as the last resort for dealing with him. Having been diagnosed with bipolar disorder, Eric spent most of his childhood in and out of hospitals. His mom compared him to Adam Lanza, a mass shooter who committed suicide, in a blog post that went viral. But Eric wasn’t an addict. If he had these tremendous difficulties since age seven, imagine what it’s like for someone who is not only mentally ill, but an addict, as well?

This is a concrete example of what runs through the mind of someone who is suffering from both addiction and mental illness:

“I’m going to be the next prime minister of Canada.” This was what Mark V. Fernandes truly believed during his episodes. This may come true one day; we never know. But Mark was diagnosed with bipolar disorder type I and alcoholism. Mental illness and alcohol abuse disorder run in his family. His brother and two aunts committed suicide. His first manic episode began at age 23. Symptoms included rarely sleeping, overspending, delusions of grandeur, sexual craving, irritability, hostility, depression, and hearing voices. These affected his relationships with colleagues and family members.

More than 20 times, he had been “certified against his will,” each time spending six to eight weeks in hospitals across Canada. His turning point was the day his dad wrote him a letter, threatening abandonment if he didn’t shape up.

How frustrating—and heartbreaking—it is for us who want to help people like Eric or Mark, but cannot fathom the complexity of what they’re going through.

How can we understand?

We can move closer to an understanding - and therefore be in a better position to offer effective and lasting help - by asking and answering a few questions.

Is there a link between the disease of addiction and mental illness?

Yes, unfortunately. Both are chronic brain diseases. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), many people diagnosed with a substance use disorder (SUD) also suffer from a mental health or behavioural disorder. The state of two or more diseases present in a patient is known as a ‘co-occurring disorder’ or ‘dual diagnosis’ or ‘comorbidity’. The conditions can occur at the same time or one right after the other. Co-occurring disorders also affect each other.

The experts confirm it. SAMHSA estimates that one in four people with a serious mental illness (SMI) also has an SUD. According to the National Survey on Drug Use and Health (NSDUH), 45% of people in the US have co-occurring disorders. Those with mental health conditions are “about twice as likely as the general population to suffer from an SUD.”

Those with a dual diagnosis need an integrated plan that will treat both disorders at the same time. Experts say this is better than addressing the disorders separately. Most studies on the relationship between substance use disorders and other mental illnesses have not included people with severe psychotic illnesses. So further research is needed to find out the cause of co-occurring disorders.

Some mental health and behavioural disorders occur repeatedly with addiction and are often the cause of that dependence.

Common ones linked to substance abuse include:

• attention deficit hyperactivity disorder (ADHD)
• bipolar disorder
• borderline personality disorder (BPD)
• depression
• eating disorders
• obsessive-compulsive disorder (OCD)
• post-traumatic stress disorder (PTSD)
• schizophrenia
• generalized anxiety disorder (GAD)

For more information about addiction and mental illness in Canada, see the statistics quoted after the main article.

Substance abuse: clutching at crutches

GAD is the most common mental health condition in the US, affecting 18% of the adult population. To manage panic attacks, GAD patients tend to abuse alcohol and prescription medications like benzodiazepines (brands Xanax or Valium)—associated with high rates of addiction.

As for PTSD, patients’ brains don’t produce enough endorphins (feel-good hormones), so they tend to use alcohol or drugs to hide the effects of trauma and make themselves feel better. The US Department of Veteran Affairs confirms that almost 75% of military personnel exposed to trauma or violence in combat are repetitive alcohol abusers who struggle with sobriety.

In most cases, sufferers of mental disorders become addicted as a result of trying to self- medicate with alcohol or drugs—which include stimulants (ADHD sufferers) and appetite suppressants (eating disorder patients). Substances and compulsive behaviour are usually meant to increase drive, improve cognition, alleviate pain, manage withdrawal symptoms, forget problems, escape reality, bury unpleasant memories, numb feelings, invoke feelings of pleasure, or induce relaxation in social situations.

Gamers Anonymous, anyone?

Addictive activities like gambling and excessive video game playing are also forms of self- medication. Even if gaming disorder is not common, it is now classified as a behavioural health condition in the International Classification of Diseases (ICD)-11, under the category of ‘disorders due to addictive behaviours’.

ICD is an international health information standard for recording diseases, injuries, external causes of illness and death, patient safety events, primary care, traditional medicine, and many other components relevant for recording the health of a population. The World Health Organization (WHO) released the 11th edition in June 2018 [2].

“ICD has to keep pace with evolving disorders and diseases,” says Dr. Shekhar Saxena, Director, Department of Mental Health and Substance Abuse, WHO. “Gambling disorder was included in ICD-10. Gaming disorder has now been added because of very clear scientific evidence that it has characteristic signs and symptoms, and there is need for treatment from many world regions.”

Internet addiction exists, too. Reuters reports a program called ‘Reboot’ in Ohio that offers inpatient treatment for youth with technology-related addictions [3].

Is depression recognized as a mental illness? What role does it play in addiction?

Definitely. Despite depression being common, it is listed, together with addiction, in both the Diagnostic and Statistical Manual of Mental Disorders (DSM)-V and ICD-11 under category 06: ‘mental, behavioural, or neurodevelopmental disorders’.

If I am an addict, am I mentally ill? If I am mentally ill, will I become an addict?

The National Institute on Drug Abuse (NIDA) addresses this ‘chicken-and-egg’ debate. “Although substance use disorders commonly occur with other mental illnesses, this does not mean that one caused the other, even if one appeared first. In fact, establishing which came first, or why, can be difficult.”

Dr. Nora D. Volkow, Director of NIDA, confirms: “Drug use impacts many of the same brain circuits that are disrupted in severe mental disorders, such as schizophrenia. While we cannot always prove a connection or causality, we do know that certain mental disorders are risk factors for subsequent substance use disorders, and vice versa.” Schizophrenia with addiction is even more difficult to diagnose because both disorders share some of the same symptoms.

Drug or alcohol abusers tend to develop behavioural or mental health problems alongside their original condition. The NSDUH found that, apart from environmental factors, genetics play a role in the development of an addiction or a mental disorder. Genes make up 40 to 60% of a person’s susceptibility to addiction.

Are all addicts depressed? Because not all who are depressed are addicts.

The second statement is true. As for the first, depression is only one result of a chemical imbalance in certain areas of the brain. Many people turn to alcohol or drugs to combat depression, but not all of them become addicted to these.

Therefore, depression is only a conduit, though it is one of the three main emotions (with loneliness and anxiety) most people try to manage.

Comorbidity in youth

There is robust evidence that children and adolescents with untreated ADHD have an increased risk for SUDs. Stimulant medications, like methylphenidate or amphetamine—used to address concentration problems and impulsive behaviour—have addictive potential. So treatment should combine medication with educational and behavioural interventions, including counselling.

How can cooccurring conditions be treated?

Behavioural therapies

NIDA recommends these effective modalities:

• Cognitive behavioural therapy (CBT) - helps identify thoughts and behaviours leading to drug use and replaces them with productive ones.
• Dialectical behavioural therapy (DBT) - based on CBT, this evidence-based psychotherapy focuses more on emotional and social problems.
• Motivational enhancement therapy (MET) - encourages commitment to behaviour change. Often used along with the other types of therapy.
• Motivational incentives - aka contingency management (CM), a rewards system for drug abstinence.
• Assertive community treatment (ACT) - encourages relationship-building and community involvement.
• Therapeutic communities (TC) - a group-based approach to long-term mental illness, personality disorders, and drug addiction.
• Multisystemic Therapy (MST) - targets antisocial behaviour.
• Brief Strategic Family Therapy (BSFT) - manages family interactions.
• Multidimensional Family Therapy (MDFT) - comprehensive intervention for adolescents.
• Exposure therapy - aimed at anxiety disorders (phobias, PTSD).
• Integrated Group Therapy (IGT) - developed for bipolar disorder/substance use disorder.
• Seeking Safety (SS) - present-focused therapy for trauma-related problems (PTSD) and substance use disorder.
• Mobile Medical Application - device that delivers CBT to outpatients.

Does medication help?

There are effective medications for treating nicotine, opioid, and alcohol use disorders, such as Bupropion. This is approved for treating both depression and nicotine dependence. Medications, combined with behavioural treatments, have proven successful. As with most chronic conditions such as heart disease or diabetes, comorbidity must be managed throughout the patient’s life.

Dual diagnosis recovery options

Apart from combination programs offered by rehabilitation centres and treatment providers, patients can help themselves with other action plans:

1. Identify the triggers of unpleasant feelings. Learn how to deal with them without resorting to addictive substances or impulsive behaviour.
2. Identification helps patients predict when, where, and/or how the stimulus will happen.They can then stop the event before it happens. Or have their ‘weapons’ ready.
3. Explore various therapies, even unusual ones. A method that isn’t beneficial for one patient may work for another.
4. Learn to manage stress. Therapists and counsellors teach coping skills and help develop emotional intelligence.
5. Set recovery goals with timelines, and stick to them. Patients who find this overwhelming can ask friends, family, and professionals to help. The universe wasn’t made in a day. Even God rested.
6. Group support (eg, Narcotics/Alcoholics Anonymous, Mood Disorders Association of BC in White Rock) can help with numbers 1-5.
7. See a psychiatrist who specializes in treating mood disorders.

Not so common treatment methods

Mark Fernandes recommends a form of meditation called ‘Ascension’ [4]. Another unusual interactive psychotherapy technique is Eye Movement Desensitization and Reprocessing (EMDR), employed to relieve psychological stress. While increasingly regarded as an effective treatment for PTSD, it is also being used to treat addictions.

EMDR patients recall traumatic experiences while the therapist directs eye movements. This is meant to move the patient’s attention away from distressing events. These then become less upsetting over time as the treatment progresses. Positive effects can be maintained long-term. This is why the Department of Veterans’ Affairs recommends EMDR.

Silver linings do lead to gold

Remember Eric Walton, the kid with bipolar disorder? After his condition stabilized, he delivered a TEDx Talk at age 16, detailing how he survived the horrors of his disorder. Still, he cautions, “My fight won’t be over until the day I’m in a coffin.”

He continues to lobby for acceptance and better understanding of people like him. “Yes, I have a mental illness. No, I’m not inferior to other human beings. I shouldn’t be feared.” He said that if people had treated him better, his recovery practice after the right diagnosis “would have taken six months instead of two years.”

People with mental disorders, says Eric, “should be treated with kindness, not fear and stigma. (We) are all human beings and deserve the same respect as anyone else.”

Recovery, whether from comorbidity or other conditions, is a continuous process which requires patience, willpower, and commitment. Patients shouldn’t be disheartened by relapses.

Take it from CAMH’s most promising statement: “With appropriate treatment and support, most people will recover.” This is the hope of every individual who knows someone suffering from this dual malady.

Sources:

[1] SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, Mental Health, detailed tables. https://www.samhsa.gov/data/population-data-nsduh.
[2] “Geneva: The World Health Organization (WHO) is today releasing its new International Classification of Diseases (ICD-11)”. June 18, 2018. https://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-of-diseases- (icd-11).
[3] Borter, Gabriella. “The digital drug: Internet addiction spawns US treatment programs”. Reuters online. January 27, 2019. https://www.reuters.com/article/us-usa-internet-addiction-feature/the-digital-drug-internet-addiction-spawns-u-s-treatment- programs-idUSKCN1PL0AG.
[4] www.thebrightpath.com
[5] https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics and https://www.ccsa.ca/sites/default/files/2019-04/CSUCH-Canadian-Substance-Use-Costs-Harms-Report-2018-en.pdf

STATISTICS ON DRUG ADDICTION AND MENTAL HEALTH CONDITIONS IN CANADA [5]

*From the CAMH Monitor (Centre for Addiction and Mental Health), the longest ongoing representative survey of adult substance use in Canada.

• In any given year, one in five Canadians experiences a mental health issue or addiction problem.
• Young people aged 15 to 24 are more likely to experience mental illness and/or substance use disorders than any other age group.
• People with a mental illness are twice as likely to have a substance use disorder compared to the general population. At least 20% of people with mental health disorders have a cooccurring substance use problem. For people with schizophrenia, the number may be as high as 50%.
• Men have higher rates of addiction than women, while women have higher rates of mood and anxiety disorders.
• People with substance use problems are up to three times more likely to have a mental illness. More than 15% of people with a substance use problem have a cooccurring mental illness.
• People with mental health problems and addictions are more likely to die prematurely than the general population. Mental illness can cut 10 to 20 years from a person’s life expectancy.
• The disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together and more than seven times that of all infectious diseases.
• Stigma: According to a 2008 survey, just 50% of Canadians would tell friends or co-workers that they have a family member with a mental illness, compared to 72% who would discuss a diagnosis of cancer and 68% who would talk about a family member having diabetes.
• Access to services: While mental illness accounts for about 10% of the burden of disease in Ontario, it receives just 7% of health care dollars. Relative to this burden, mental health care in Ontario is underfunded by about $1.5 billion.
• Statistics on children and youth: An estimated 75% of children with mental disorders do not access specialized treatment services.
• From 2013 to 2014, 5% of emergency room visits and 18% of inpatient hospitalizations for children and youth aged 5 to 24 in Canada were for a mental disorder.
• Counselling and therapy wait periods are lengthier for younger people. In Ontario, mean wait time is six months to one year.
• NB: The Mood Disorders Association of British Columbia (MDA), a support group in White Rock, has a Group Medical Visits program that can expedite access to medical help. See: www.mdabc.net/group-medical-visits.

Photo credit: Trending Topics 2019. This picture has a Creative Commons attribution license.