1 Is there a relationship between childhood ADHD and later drug See page 2. abuse? from the director: Comorbidity is a topic that our stakeholders––patients, family members, health care professionals, and others–– Comorbidity: frequently ask about. It is also a topic about which we have insufficient information, Addiction and Other Mental Illnesses so it remains a research priority for NIDA. This Research Report provides information on the state of the science in this area. Although a variety of diseases commonly co-occur with drug abuse and addiction (e.g., HIV, hepatitis C, cancer, cardiovascular disease), this report focuses only on the comorbidity of drug use disorders and other mental illnesses.* To help explain this comorbidity, we need to first recognize that drug addiction is a mental illness. It is a complex brain disease characterized by compulsive, at times uncontrollable drug craving, seeking, and use despite devastating consequences— behaviors that stem from drug-induced changes in brain structure and function. These changes occur in some of the same brain areas that are disrupted in other mental disorders, such as depression, anxiety, or schizophrenia. It is therefore not surprising that population surveys show a high rate of co-occurrence, or comorbidity, between drug addiction and other mental illnesses. While we cannot always prove a What Is connection or causality, we do know that certain mental disorders are established Comorbidity? risk factors for subsequent drug abuse— and vice versa. hen two disorders or illnesses occur in the same It is often difficult to disentangle the overlapping symptoms of drug addiction person, simultaneously or sequentially, they and other mental illnesses, making diagnosis and treatment complex. Correct are described as comorbid. Comorbidity also W diagnosis is critical to ensuring appropriate and effective treatment. Ignorance of or implies interactions between the illnesses that affect the failure to treat a comorbid disorder can jeopardize a patient’s chance of recovery. course and prognosis of both. We hope that our enhanced understanding continued inside of the common genetic, environmental, and neural bases of these disorders—and the dissemination of this information—will lead *Since the focus of this report is on comorbid drug use disorders and to improved treatments for comorbidity and other mental illnesses, the terms “mental illness” and “mental disorders” will diminish the social stigma that makes patients reluctant to seek the treatment will refer here to disorders other than substance use disorders, such as they need. depression, schizophrenia, anxiety, and mania. The terms “dual diagnosis,” “mentally ill chemical abuser,” and “co-occurrence” are also used to refer to Nora D. Volkow, M.D. drug use disorders that are comorbid with other mental illnesses. Director National Institute on Drug Abuse

2 Comorbidity Research R eport S eries How Common Is Drug Addiction Are Comorbid a Mental Illness? Drug Use and Yes, because addiction changes the brain in fundamental ways, Other Mental disturbing a person’s normal Disorders? hierarchy of needs and desires Many people who regularly and substituting new priorities abuse drugs are also diagnosed connected with procuring and Childhood ADHD with mental disorders and vice using the drug. The resulting and Later Drug versa. The high prevalence of this compulsive behaviors that Problems comorbidity has been documented override the ability to control in multiple national population impulses despite the consequences Numerous studies have surveys since the 1980s. Data are similar to hallmarks of other documented an increased risk for show that persons diagnosed mental illnesses. drug use disorders in youth with with mood or anxiety disorders In fact, the DSM, which is the untreated ADHD, although some are about twice as likely to suffer definitive resource of diagnostic suggest that only a subset of also from a drug use disorder criteria for all mental disorders, these individuals are vulnerable: (abuse or dependence) compared those with comorbid conduct with respondents in general. The disorders. Given this linkage, it is important to determine whether same is true for those diagnosed Addiction effective treatment of ADHD with an antisocial syndrome, changes the could prevent subsequent drug such as antisocial personality brain, disturbing abuse and associated behavioral or conduct disorder. Similarly, the normal problems. Treatment of childhood persons diagnosed with drug ADHD with stimulant medications hierarchy of disorders are roughly twice as such as methylphenidate or needs and likely to suffer also from mood amphetamine reduces the desires. and anxiety disorders (see page 3, impulsive behavior, fidgeting, “Overlapping Conditions— Shared and inability to concentrate that characterize ADHD. Yet, Vulnerability”). some physicians and parents Gender is also a factor in the drug use includes criteria for have expressed concern that specific patterns of observed disorders , distinguishing between treating childhood ADHD with comorbidities. For example, two types: drug abuse and drug stimulants might increase a child’s the overall rates of abuse and dependence. Drug dependence vulnerability to drug abuse later in dependence for most drugs tend is synonymous with addiction. life. Recent reviews of long-term to be higher among males than By comparison, the criteria for studies of children with ADHD females. Further, males are more hinge on the harmful drug abuse who were treated with stimulant likely to suffer from antisocial medications (e.g., Adderal, Ritalin, consequences of repeated use but personality disorder, while women Concerta) found no evidence for do not include the compulsive this increase. However, most of have higher rates of mood and use, tolerance (i.e., needing higher these studies have methodological anxiety disorders, all of which are doses to achieve the same effect), limitations, including small sample risk factors for substance abuse. or withdrawal (i.e., symptoms that sizes and nonrandomized study occur when use is stopped) that designs, indicating that more can be signs of addiction. research is needed, particularly with adolescents. NIDA Research Report Series 2

3 Overlapping Conditions—Shared Vulnerability High Prevalence of Drug Abuse and Dependence Why Do Drug Use Among Individuals With Mood and Anxiety Disorders Disorders Often Co- 25 Occur With Other All respondents Mental Illnesses? Any mood disorder 20 Any anxiety disorder The high prevalence of comorbidity 15 between drug use disorders and other mental illnesses does not mean that one 10 caused the other, even if one appeared first. In fact, establishing causality or Because mood disorders increase vulnerability to directionality is difficult for several 5 drug abuse and addiction, reasons. Diagnosis of a mental disorder the diagnosis and may not occur until symptoms have 0% treatment of the mood Amphetamines Marijuana Cocaine Opioids Any Drug progressed to a specified level (per disorder can reduce the DSM); however, subclinical symptoms risk of subsequent drug Higher Prevalence of Mental Disorders may also prompt drug use, and use. Because the inverse Among Patients With Drug Use Disorders may also be true, the imperfect recollections of when drug use diagnosis and treatment 50 or abuse started can create confusion as of drug use disorders to which came first. Still, three scenarios All respondents may reduce the risk of deserve consideration: 40 developing other mental Any drug use disorder illnesses and, if they do 1. Drugs of abuse can cause abusers to occur, lessen their severity experience one or more symptoms of 30 or make them more another mental illness. The increased amenable to effective risk of psychosis in some marijuana treatment. Finally, 20 abusers has been offered as evidence because more than 40 percent of the cigarettes for this possibility. 10 smoked in this country Mental illnesses can lead to drug 2. are smoked by individuals abuse. Individuals with overt, mild, with a psychiatric disorder, 0% such as major depressive or even subclinical mental disorders Mood Disorders Anxiety Disorders disorder, alcoholism, post- may abuse drugs as a form of self- traumatic stress disorder medication. For example, the use (PTSD), schizophrenia, or Higher Prevalence of Smoking Among of tobacco products by patients bipolar disorder, smoking Patients With Mental Disorders with schizophrenia is believed to by patients with mental lessen the symptoms of the disease 80 illness contributes Current smokers greatly to their increased and improve cognition (see page 70 morbidity and mortality. 4, “Smoking and Schizophrenia: 60 Self-Medication or Shared Brain 50 Circuitry?”). 40 Both drug use disorders and 3. other mental illnesses are caused 30 by overlapping factors such as 20 underlying brain deficits, genetic 10 vulnerabilities, and/or early exposure to stress or trauma. 0% No Mental Major Alcohol Bipolar Post-Traumatic Drug Illness Depression Abuse or Disorder Stress Abuse or All three scenarios probably contribute, Dependence Disorder Dependence in varying degrees, to how and whether specific comorbidities manifest Data in top two graphs reprinted from the National Epidemiologic Survey on Alcohol and Related Conditions (Conway et al., 2006). themselves. Data in bottom graph from the 1989 U.S. National Health Interview Survey (Lasser et al., 2000). NIDA Research Report Series 3

4 Common Factors - Overlapping Genetic Vulnera bilities. A particularly active area of comorbidity research involves the search for genes that might predis - - pose individuals to develop both ad diction and other mental illnesses, or to have a greater risk of a second disorder occurring after the first appears. It is estimated that 40–60 The rate of smoking percent of an individual’s vulner - ability to addiction is attributable to in patients with genetics; most of this vulnerability arises from complex interactions schizophrenia has among multiple genes and from ge - ranged as high as 90 netic interactions with environmen - tal influences. In some instances, percent. a gene product may act directly, as when a protein influences how a person responds to a drug (e.g., Smoking and Schizophrenia: Self- - whether the drug experience is plea surable or not) or how long a drug Medication or Shared Brain Circuitry? remains in the body. But genes can Patients with schizophrenia have higher rates of alcohol, tobacco, and also act indirectly by altering how other drug abuse than the general population. Based on nationally an individual responds to stress representative survey data, 41 percent of respondents with past-month or by increasing the likelihood of mental illnesses are current smokers, which is about double the rate of risk-taking and novelty-seeking be - those with no mental illness. In clinical samples, the rate of smoking in haviors, which could influence the patients with schizophrenia has ranged as high as 90 percent. development of drug use disorders Various self-medication hypotheses have been proposed to explain the and other mental illnesses. Several strong association between schizophrenia and smoking, although none regions of the human genome have have yet been confirmed. Most of these relate to the nicotine contained been linked to increased risk of both in tobacco products: Nicotine may help compensate for some of the drug use disorders and mental ill - cognitive impairments produced by the disorder and may counteract ness, including associations with psychotic symptoms or alleviate unpleasant side effects of antipsychotic greater vulnerability to adolescent medications. Nicotine or smoking behavior may also help people with drug dependence and conduct dis - schizophrenia deal with the anxiety and social stigma of their disease. orders. Research on how both nicotine and schizophrenia affect the brain has Involvement of Similar Brain generated other possible explanations for the high rate of smoking Regions. Some areas of the brain among people with schizophrenia. The presence of abnormalities in particular circuits of the brain may predispose individuals to schizophrenia, are affected by both drug use dis - increase the rewarding effects of drugs like nicotine, or reduce an orders and other mental illnesses. individual’s ability to quit smoking. The involvement of common For example, the circuits in the mechanisms is consistent with the observation that both nicotine and brain that use the neurotransmitter the medication clozapine (which also acts at nicotine receptors, among dopamine—a chemical that carries others) can improve attention and working memory in an animal model messages from one neuron to an - of schizophrenia. Clozapine is effective in treating individuals with - other—are typically affected by ad schizophrenia. It also reduces their smoking levels. Understanding how dictive substances and may also be and why patients with schizophrenia use nicotine is likely to help us involved in depression, schizophre - develop new treatments for both schizophrenia and nicotine dependence. nia, and other psychiatric disorders. NIDA Research Report Series 4

5 Indeed, some antidepressants and essentially all antipsychotic The brain continues to develop into medications directly target the regulation of dopamine in this adulthood and undergoes dramatic system, whereas others may have changes during adolescence. - indirect effects. Importantly, dopa mine pathways have also been im - One of the brain areas still maturing during adolescence is the prefrontal plicated in the way in which stress cortex—the part of the brain that enables us to assess situations, make can increase vulnerability to drug sound decisions, and keep our emotions and desires under control. addiction. Stress is also a known The fact that this critical part of an adolescent’s brain is still a work in progress puts them at increased risk for poor decisions (such as trying risk factor for a range of mental drugs or continuing abuse). Thus, introducing drugs while the brain is still disorders and therefore provides developing may have profound and long-lasting consequences. one likely common neurobiological link between the disease processes of addiction and those of other AGES mental disorders. 20 5 The overlap of brain areas in - volved in both drug use disorders and other mental illnesses sug - gests that brain changes stemming from one may affect the other. For example, drug abuse that precedes the first symptoms of a mental illness may produce changes in brain structure and function that kindle an underlying propensity to develop that mental illness. If the mental disorder develops first, - associated changes in brain activ ity may increase the vulnerability - to abusing substances by enhanc ing their positive effects, reducing awareness of their negative effects, - or alleviating the unpleasant ef fects associated with the mental Early Occurrence Increases be seen among youth. Significant disorder or the medication used to Later Risk. treat it. Strong evidence has changes in the brain occur during adolescence, which may enhance emerged showing early drug use to The Influence of be a risk factor for later substance vulnerability to drug use and the - development of addiction and Developmental Stage abuse problems; additional find ings suggest that it may also be a Adolescence—A Vulnerable other mental disorders. Drugs of abuse affect brain circuits involved Although drug abuse and risk factor for the later occurrence Time. of other mental illnesses. How - addiction can happen at any time in learning and memory, reward, decisionmaking, and behavioral ever, this link is not necessarily a use during a person’s life, drug typically starts in adolescence, simple one and may hinge upon control, all of which are still maturing into early adulthood. - genetic vulnerability, psychoso a period when the first signs of mental illness commonly appear. Thus, understanding the long-term cial experiences, and/or general environmental influences. A 2005 It is therefore not surprising that impact of early drug exposure is a comorbid disorders can already critical area of comorbidity research. study highlights this complexity, NIDA Research Report Series 5

6 The high rate of comorbidity between drug abuse and addiction and other mental disorders argues for a comprehensive approach to intervention that identifies and evaluates each disorder concurrently, providing treatment as needed. with the finding that frequent marijuana use during adolescence can increase the risk of psychosis in adulthood, but only in individu - The Influence of Adolescent als who carry a particular gene Marijuana Use on Adult Psychosis variant (see sidebar, “The Influ - Is Affected by Genetic Variables ence of Adolescent Marijuana Use on Adult Psychosis Is Affected by Genetic Variables”). Percentage of Individuals It is also true that having a mental disorder in childhood Meeting Diagnostic Criteria for Schizophreniform Disorder at Age 26 or adolescence can increase the risk of later drug abuse prob - 15 lems, as frequently occurs with conduct disorder and untreated 12 attention-deficit hyperactivity No adolescent cannabis use disorder (ADHD). This presents a Adolescent cannabis use challenge when treating children 9 with ADHD, since effective treat - ment often involves prescribing 6 stimulant medications with abuse potential. This issue has generated 3 strong interest from the research - community, and although the re 0% sults are not yet conclusive, most Val/Met Val/Val Met/Met studies suggest that ADHD medi - Source: Caspi A, Moffitt TE, Cannon M, et al., 2005. cations do not increase the risk of drug abuse among children with ADHD (see page 2, “Childhood The above figure shows that variations in a gene can affect the likelihood ADHD and Later Drug Problems”). of developing psychosis in adulthood following exposure to cannabis Regardless of how comorbidity in adolescence. The catechol- O -methyltransferase gene regulates an enzyme that breaks down dopamine, a brain chemical involved in develops, it is common in youth schizophrenia. It comes in two forms: Met and Val. Individuals with as well as adults. Given the high one or two copies of the Val variant have a higher risk of developing prevalence of comorbid mental schizophrenic-type disorders if they used cannabis during adolescence - disorders and their likely ad (dark bars). Those with only the Met variant were unaffected by cannabis verse impact on substance abuse use. These findings hint at the complexity of factors that contribute to treatment outcomes, drug abuse comorbid conditions. programs for adolescents should include screening and, as needed, treatment for comorbid mental disorders. NIDA Research Report Series 6

7 9, “Barriers to Comprehensive How Can Treatment of Comorbidity”). Patients who have both a drug Comorbidity Be use disorder and another mental Diagnosed? illness often exhibit symptoms that are more persistent, severe, and The high rate of comorbidity between drug use disorders and resistant to treatment compared other mental illnesses argues with patients who have either disorder alone. Nevertheless, for a comprehensive approach to intervention that identifies steady progress is being made through research on new and and evaluates each disorder existing treatment options concurrently, providing treatment for comorbidity and through as needed. The needed approach health services research on calls for broad assessment tools implementation of appropriate that are less likely to result in a screening and treatment within missed diagnosis. Accordingly, Behavioral Therapies a variety of settings, including patients entering treatment Behavioral treatment (alone or in criminal justice systems. for psychiatric illnesses should also be screened for substance combination with medications) is the cornerstone to successful use disorders and vice versa. Accurate diagnosis is complicated, outcomes for many individuals however, by the similarities with drug use disorders or other between drug-related symptoms mental illnesses. And while behavior therapies continue to such as withdrawal and those be evaluated for use in comorbid of potentially comorbid mental disorders. Thus, when people who populations, several strategies abuse drugs enter treatment, it have shown promise for treating may be necessary to observe them specific comorbid conditions (see after a period of abstinence in page 8, “Examples of Promising Medications order to distinguish between the Behavioral Therapies for Patients effects of substance intoxication With Comorbid Conditions”). Effective medications exist Most clinicians and for treating opioid, alcohol, or withdrawal and the symptoms and nicotine addiction and for of comorbid mental disorders. researchers agree that broad This practice would allow for a spectrum diagnosis and alleviating the symptoms of concurrent therapy will lead more accurate diagnosis and more many other mental disorders, yet to more positive outcomes targeted treatment. most have not been well studied for patients with comorbid in comorbid populations. Some conditions. Preliminary findings medications may benefit multiple problems. For example, evidence support this notion, but research How Should suggests that bupropion (trade is needed to identify the most Comorbid names: Wellbutrin, Zyban), effective therapies (especially studies focused on adolescents). approved for treating depression Conditions Be and nicotine dependence, might Treated? also help reduce craving and use A fundamental principle emerging of the drug methamphetamine. Clearly, more research is needed from scientific research is the need to treat comorbid conditions to fully understand and assess concurrently—which can be a the actions of combined or dually difficult proposition (see page effective medications. NIDA Research Report Series 7

8 Examples of Promising Behavioral Therapies for Patients with Comorbid Conditions Adolescents Multisystemic Therapy (MST) MST targets key factors (attitudes, family, peer pressure, school and neighborhood culture) associated with serious antisocial behavior in children and adolescents who abuse drugs. Brief Strategic Family Therapy (BSFT) BSFT targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co- Dialectical Behavior Therapy (DBT) occurring problem behaviors. These DBT is designed specifically to reduce Adults problem behaviors include conduct self-harm behaviors (such as self- problems at home and at school, mutilation and suicidal attempts, oppositional behavior, delinquency, Therapeutic Communities (TCs) thoughts, or urges) and drug abuse. associating with antisocial peers, TCs focus on the “resocialization” of It is one of the few treatments that aggressive and violent behavior, and the individual and use broad-based is effective for individuals who meet risky sexual behaviors. community programs as active the criteria for borderline personality components of treatment. TCs are disorder. Cognitive-Behavioral Therapy (CBT) particularly well suited to deal with CBT is designed to modify harmful criminal justice inmates, individuals Exposure Therapy beliefs and maladaptive behaviors. CBT with vocational deficits, women who Exposure therapy is a behavioral is the most effective psychotherapy need special protections from harsh treatment for some anxiety disorders for children and adolescents with social environments, vulnerable (phobias, PTSD) that involves repeated anxiety and mood disorders, and also or neglected youth, and homeless exposure to or confrontation with a shows strong efficacy for substance individuals. In addition, some evidence feared situation, object, traumatic event, abusers. (CBT is also effective for suggests the utility of incorporating or memory. This exposure can be real, adult populations suffering from drug TCs for adolescents who have been visualized, or simulated, and always is use disorders and a range of other in treatment for substance abuse and contained in a controlled therapeutic psychiatric problems.) related problems. environment. The goal is to desensitize patients to the triggering stimuli and help Assertive Community Treatment them learn to cope, eventually reducing (ACT) or even eliminating symptoms. Several ACT programs integrate the behavioral studies suggest that exposure therapy treatment of other severe mental may be helpful for individuals with disorders, such as schizophrenia, and comorbid PTSD and cocaine addiction, co-occurring substance use disorders. although retention in treatment is ACT is differentiated from other forms difficult. of case management through factors such as a smaller caseload size, team Integrated Group Therapy (IGT) management, outreach emphasis, a IGT is a new treatment developed highly individualized approach, and specifically for patients with bipolar an assertive approach to maintaining disorder and drug addiction, designed to contact with patients. address both problems simultaneously. NIDA Research Report Series 8

9 Exposure to Traumatic Events Puts People at Higher Risk of Substance Use Disorders Physically or emotionally traumatized Barriers to Comprehensive people are at much higher risk of abusing licit, illicit, and prescription Treatment of Comorbidity drugs. This linkage is of particular concern for returning veterans Although research supports the need for comprehensive treatment to since nearly 1 in 5 military address comorbidity, provision of such treatment can be problematic for a service members back from Iraq number of reasons: and Afghanistan have reported symptoms of post-traumatic stress • In the United States, different treatment systems address drug use disorder (PTSD) or major depression. disorders and other mental illnesses separately. Physicians are most Recent epidemiological studies often the front line of treatment for mental disorders, whereas drug suggest that as many as half of all abuse treatment is provided in assorted venues by a mix of health veterans diagnosed with PTSD also care professionals with different backgrounds. Thus, neither system may have sufficiently broad expertise to address the full range of have a co-occurring substance use problems presented by patients. People also use these health care disorder (SUD), which could pose an systems differently, depending on insurance coverage and social enormous challenge for our health factors. For example, when suffering from substance abuse and care system. Many PTSD programs mental illness comorbidities, women more often seek help from do not accept individuals with active mental health practitioners, whereas men tend to seek help through SUDs, and traditional SUD clinics substance abuse treatment channels. defer treatment of trauma-related issues. Nevertheless, there are • A lingering bias remains in some substance abuse treatment centers treatments at different stages of against using any medications, including those necessary to treat clinical validation for comorbid PTSD serious mental disorders such as depression. Additionally, many and SUD; these include various substance abuse treatment programs do not employ professionals combinations of psychosocial (e.g., qualified to prescribe, dispense, and monitor medications. exposure therapy) and pharmacologic (e.g., mood stabilizers, anxiolytics, • Many of those needing treatment are in the criminal justice system. and antidepressants) interventions. It is estimated that about 45 percent of offenders in State and However, research is urgently local prisons and jails have a mental health problem comorbid with needed to identify the best substance abuse or addiction. However, adequate treatment services treatment strategies for addressing for both drug use disorders and other mental illnesses are greatly PTSD/SUD comorbidities, and to lacking within these settings. While treatment provision may be explore whether different treatments burdensome for the criminal justice system, it offers an opportunity to might be needed in response to positively affect the public’s health and safety. Treatment of comorbid civilian versus combat PTSD. disorders can reduce not only associated medical complications, but also negative social outcomes by mitigating against a return to criminal behavior and reincarceration. NIDA Research Report Series 9

10 Glossary Addiction: A disorder marked Depression: Neurotransmitter: A chemical A chronic, relapsing by sadness, inactivity, difficulty produced by neurons to carry disease characterized by compulsive drug seeking and use and by long- with thinking and concentration, messages from one nerve cell to lasting changes in the brain. significant increase or decrease another. in appetite and time spent sleeping, feelings of dejection and Post-Traumatic Stress Disorder A Antisocial Personality Disorder: hopelessness, and, sometimes, (PTSD): A disorder that develops disorder characterized by antisocial suicidal thoughts or an attempt to behaviors that involve pervasive after exposure to a highly stressful commit suicide. disregard for and violation of the event (e.g., wartime combat, rights, feelings, and safety of others. physical violence, or natural disaster). A brain chemical, Dopamine: Symptoms include sleeping These behaviors begin in early classified as a neurotransmitter, difficulties, hypervigilance, avoiding childhood (conduct disorder) or the found in regions of the brain that reminders of the event, and re- early teenage years and continue into adulthood. experiencing the trauma through regulate movement, emotion, motivation, and pleasure. flashbacks or recurrent nightmares. Varied Anxiety Disorders: A mental disorder (e.g., disorders that involve excessive or Dual Diagnosis/Mentally Ill Psychosis: inappropriate feelings of anxiety or Other Chemical Abuser (MICA): schizophrenia) characterized by worry. Examples are panic disorder, terms used to describe the delusional or disordered thinking detached from reality; symptoms PTSD, social phobia, and others. comorbidity of a drug use disorder often include hallucinations. and another mental illness. Attention-Deficit Hyperactivity A mood A disorder that A psychotic disorder Schizophrenia: Major Depressive Disorder: Disorder (ADHD): characterized by symptoms that typically presents in early childhood, disorder having a clinical course of characterized by inattention, fall into two categories: (1) positive one or more serious depression symptoms, such as distortions in hyperactivity, and impulsivity. episodes that last 2 or more weeks. Episodes are characterized by a loss thoughts (delusions), perception of interest or pleasure in almost all (hallucinations), and language and A mood disorder Bipolar Disorder: activities; disturbances in appetite, thinking and (2) negative symptoms, characterized by alternating such as flattened emotional sleep, or psychomotor functioning; episodes of depression and mania or responses and decreased goal- a decrease in energy; difficulties in hypomania. thinking or making decisions; loss of directed behavior. self-esteem or feelings of guilt; and Comorbidity: The occurrence of two suicidal thoughts or attempts. Self-Medication: The use of a disorders or illnesses in the same substance to lessen the negative person, either at the same time Mania: effects of stress, anxiety, or other A mood disorder (co-occurring comorbid conditions) characterized by abnormally and mental disorders (or side effects or with a time difference between of their pharmacotherapy). Self- persistently elevated, expansive, or the initial occurrence of one and irritable mood; mental and physical medication may lead to addiction the initial occurrence of the other hyperactivity; and/or disorganization and other drug- or alcohol-related (sequentially comorbid conditions). of behavior. problems. Conduct Disorder: A repetitive and A mental condition Mental Disorder: persistent pattern of behavior in marked primarily by sufficient children or adolescents in which the disorganization of personality, mind, basic rights of others or major age- and emotions to seriously impair the appropriate societal norms or rules normal psychological or behavioral are violated. functioning of the individual. Addiction is a mental disorder. NIDA Research Report Series 10

11 References Rand Corporation. Online Summary: Biederman, J.; Monuteaux, M.C.; James, D.J., and Glaze, L.E. Mental health problems of prison and Spencer, T.; Wilens, T.E.; Invisible wounds of war— Macpherson, H.A.; and Faraone, Psychological and cognitive Bureau of Justice jail inmates. injuries, their consequences, Statistics Special Report S.V. Stimulant therapy and risk . U.S. for subsequent substance use Department of Justice, 2006 and services to assist recovery disorders in male adults with (available at http://bjs.ojp.usdoj. (T. Tanielian and L. Jaycox, eds). ADHD: A naturalistic controlled Retrieved July 19, 2010 from gov/content/pub/pdf/mhppji.pdf). http://www.rand.org/pubs/ Am J 10-year follow up study. 165(5):597–603, 2008. monographs/MG720/ . Kessler, R.C. The epidemiology of Psychiatry dual diagnosis. Biol Psychiatry Brady, K.T., and Verduin, M.L. 56:730–737, 2004. Riggs, P.D. Treating adolescents for Pharmacotherapy of comorbid substance abuse and comorbid Lasser, K.; Boyd, J.W.; Woolhandler, Sci Pract psychiatric disorders. mood, anxiety, and substance Perspect 2(1):18–28, 2003. use disorders. Subst Use Misuse S.; Himmelstein, D.U.; McCormick, D.; and Bor, D.H. 40:2021–2041; 2043–2048, 2005. Saal, D.; Dong, Y.; Bonci, A.; and Smoking and mental illness: A Caspi, A.; Moffitt, T.E.; Cannon, Malenka, R.C. Drugs of abuse population-based prevalence JAMA study. and stress trigger a common M.; McClay, J.; Murray, R.; 284(20):2606–2610, Harrington, H.; Taylor, A.; synaptic adaptation in dopamine 2000. 37(4):577–582, neurons. Arseneault, L.; Williams, B.; Neuron Mannuzza, S.; Klein, R.G.; 2003. Braithwaite, A.; Poulton, R.; Truong, N.L.; Moulton, J.L. and Craig, I.W. Moderation of Uhl, G.R., and Grow, R.W. The burden III; Roizen, E.R.; Howell, K.H.; the effect of adolescent-onset of complex genetics in brain and Castellanos, F.X. Age of cannabis use on adult psychosis methylphenidate treatment Arch Gen Psychiatry disorders. by a functional polymorphism in initiation in children with ADHD the catechol-O-methyltransferase 61(3):223–229, 2004. and later substance abuse: gene: Longitudinal evidence of a Volkow, N.D. The reality of Prospective follow-up into gene x environment interaction. 57(10):1117–1127, comorbidity: Depression and drug adulthood. Biol Psychiatry Am J Psychiatry 2005. 56(10):714– Biol Psychiatry abuse. 165(5):604-609, 2008. 717, 2004. Compton, W.M.; Conway, K.P.; Negrete, J.C. Clinical aspects of Volkow, N.D., and Li, T.-K. Drug substance abuse in persons with Stinson, F.S.; Colliver, J.D.; and Can J Psychiatry addiction: The neurobiology of Grant, B.F. Prevalence, correlates, schizophrenia. Nat Rev 48(1):14–21, 2003. and comorbidity of DSM-IV behavior gone awry. 5(12):963–970, 2004. Neurosci antisocial personality syndromes and alcohol and specific drug Nestler, E.J., and Carlezon, W.A. use disorders in the United Jr. The mesolimbic dopamine Weiss, R.D.; Griffin, M.L.; Kolodziej, States: Results from the National M.E.; Greenfield, S.F.; Najavits, reward circuit in depression. Biol Psychiatry 59(12):1151–1159, Epidemiologic Survey on Alcohol L.M.; Daley, D.C.; Doreau, H.R.; and Related Conditions. J Clin 2006. and Hennen, J.A. A randomized Psychiatry trial of integrated group therapy 66(6):677–685, 2005. versus group drug counseling for Quello, S.B.; Brady, K.T.; and Sonne, S.C. Mood disorders and patients with bipolar disorder and Conway, K.P.; Compton, W.; Stinson, substance abuse disorders: A F.S.; and Grant, B.F. Lifetime Am J substance dependence. 164(1):100–107, 2007. complex comorbidity. Science & comorbidity of DSM-IV mood and Psychiatry Practice Perspectives 3(1):13–24, anxiety disorders and specific 2005. Wilens, T.E.; Faraone, S.V.; drug use disorders: Results from the National Epidemiologic Biederman, J.; and Gunawardene, Survey on Alcohol and Related S. Does stimulant therapy of Rand Corporation. News Release, Conditions. J Clin Psychiatry attention-deficit/hyperactivity April 17, 2008: One in five Iraq disorder beget later substance and Afghanistan veterans suffer 67(2):247–257, 2006. from PTSD or major depression. abuse? A meta-analytic review Retrieved July 19, 2010 from of the literature. Pediatrics http://www.rand.org/news/ 111(1):179–185, 2003. press/2008/04/17/. NIDA Research Report Series 11

12 Where Can I Get More Scientific Information on Where can I get more scientific Comorbid Addiction and Other Mental Illnesses? information on comorbid addiction and other mental illnesses? NIDA Web Sites To learn more about drug use disorders and other mental illnesses, or to order materials on these drugabuse.gov To learn more about drug abuse topics free of charge in English or Spanish, visit the and other mental illnesses, con - backtoschool.drugabuse.gov NIDA Web site at www.drugabuse.gov or contact tact... smoking.drugabuse.gov Research Dissemination Center at the DrugPubs hiv.drugabuse.gov 877-NIDA-NIH (877-643-2644; TTY/TDD: 240-645-0228). marijuana-info.org clubdrugs.gov steroidabuse.gov teens.drugabuse.gov inhalants.drugabuse.gov What’s New on the NIDA Web Site • Information on drugs of abuse Other Web Sites • Publications and communications (including NIDA Information on drug abuse and other mental illnesses and Addiction Science & Clinical Practice Notes is also available through these other Web sites: journal) www.nimh. • National Institute of Mental Health: • Calendar of events nih.gov • Links to NIDA organizational units • National Institute on Alcohol Abuse and • Funding information (including program Alcoholism: www.niaaa.nih.gov announcements and deadlines) Substance Abuse and Mental Health Services • • International activities Administration Health Information Network: www.samhsa.gov/shin • Links to related Web sites (access to Web sites of many other organizations in the field) NIH Publication Number 10-5771 Printed December 2008, Revised September 2010 Feel free to reprint this publication.

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