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Substance Abuse Treatment Modalities: Literature Review

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Psychiatric Care

Psychiatric care refers to clinical services where the provider is trained in psychiatry. These services obviously can overlap with any of the other treatment modalities. Two types of psychiatric treatment warrant consideration, however, and it should also be noted that one of the two major diagnostic classification systems for mental health disorders derives from the discipline of psychiatry. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the system most widely used in North America, was produced by the American Psychiatric Association (1994). The DSM-IV established two major diagnostic categories for substance use disorders, dependence and abuse. Dependence refers to more serious disorders, and abuse is used to refer to minor problems or those that have not been present long enough to qualify for the dependence diagnosis. The other major classification system is the International Classification of Diseases, Version 10, and was established by the World Health Organization with substantial psychiatric input. The categories established, harmful use and dependence, are similar to the DSM-IV categories, but the harmful use category does not capture and many cases as the substance abuse criteria (Grant, 1993). When formal diagnosis are made in Canada, they most often are based on DSM-IV criteria. Technically, in most and perhaps all provinces and territories formal diagnoses can only be made by a physician or a psychologist.

The two psychiatric treatment activities that deserve special consideration are the treatment of psychiatric comorbitiy, and the use of psychotropic medications. In each case, the main professionals involved in supervising these sorts of treatments tend to be physicians and particularly psychiatrists. There is now good epidemiological evidence that a substantial number of persons with substance use disorders also qualify for a diagnosis of having a concurrent mental disorder, especially mood disorders and sociopathy (Anthony, Warner & Kessler, 1994; Kessler, 1991; Kushner, Sher & Beitman, 1990; Reiger et al., 1990). It has also been shown that persons with a substance use disorder plus an associated mental health disorder tend to have poorer treatment outcomes than persons who do not have a comorbid disorder (McLellan, 1986; Reich & Green, 1991). An as yet unanswered question, however, is in which cases it is beneficial to treat the disorders simultaneously or by the same treatment, versus sequentially, and whether treatment of the mental disorder enhances substance use treatment outcome. Hypothetically, some mental disorders may be functionally linked to substance use disorders, for example if an individual abuses alcohol or other drugs as self-medication for an anxiety disorder (Khantzian, 1985, Kushner et al., 1990). If this is the case, it would be predicted that in order to resolve the substance use problem, the linked disorder would also have to be treated effectively. Empirical research is needed to test this hypothesis. Despite the current lack of evidence about how best to treat comorbid disorders, programs that have the services of psychiatrists available are likely to address the mental disorders in treatment.

References for Psychiatric Care

Anthony, J.C., Warner, L.A., & Kessler, R.C. (1994), “Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey”, Experimental and Clinical Psychopharmacology, 2, 244-268.

American Psychiatric Association, (1994). Diagnostic and statistical manual of mental disorders (4th Ed). Washington, DC: American Psychiatric Association.

Grant, B.F. (1993), “Nosological comparison”, Alcoholism: Clinical and Experimental Research, 17, 1093-1101.

Kessler, R.C. (1991), Comorbidity of substance use disorders and other psychiatric disorders: An ADAAMHA report on prevalence, etiology, implication for prevention, course of illness and research, Paper presented at the ,Unpublished manuscript, University of Michigan.

Khantzian, E.J. (1985), “The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence”, American Journal of Psychiatry, 142, 1259-1264.

Kushner, M.G. Sher, K.J. & Beitman, B.D. (1990), “The relation between alcohol problems and the anxiety disorders”, American Journal of Psychiatry, 147, 685-695.

McLellan, A.T. (1986), “Psychiatric severity as a predictor of outcome from substance abuse treatments”, In R.E. Meyers (Ed.), Psychopathology and addictive disorders, New York: Guilford Press.

Woody, G.E., McLellan, A.T., Lubrosky, L. & O'Brien, C.P. (1985), “Sociopathy and psychotherapy outcome”, Archives of General Psychiatry, 42, 1081-1086.