A United Front: Fighting SUDs and Mental Illness with Integrated Care

Living With a Mental Illness

Each year, millions of Americans face the reality of living with a mental illness such as depression or anxiety. Multiple national population surveys have found that about half of those who struggle with mental illness also suffer with a substance use disorder (SUD) and vice versa.¹  Both of these conditions are highly treatable on their own, but properly treating them at the same time can require special consideration from healthcare providers. 
This is just one of the reasons Crossroads has added anxiety and depression to our list of treatment services. We started by making it available in our clinics in Pennsylvania and Virginia, and now we’re looking to offer treatment for these disorders in more of our locations.  
Data shows high rates of SUDs co-occurring with anxiety disorders ² and depression. ³  With anxiety affecting 40 million Americans ⁴  and depression affecting 14.8 million Americans⁵, it makes sense that those conditions often overlap with other mental illnesses, including SUD. It has been found that integrated treatment for addiction and mental illness is consistently superior compared to separate treatments for each diagnosis.⁶  
Let’s take a moment to consider the comorbidity between mental illness and SUD, or how the two conditions can coexist and feed into one other. 
First, mental illness and SUDs share some common risk factors, such as genetic and epigenetic vulnerabilities and occurrence in similar areas of the brain. Environmental elements, such as early exposure to stress or trauma,⁷ can also influence both conditions.
A reason for the differences in reported prevalence rates is the complexity of diagnostic issues that mood disorders and SUDs share. For example, because abstinence from drugs can temporarily depress mood, a patient who is evaluated while in withdrawal may be misdiagnosed as suffering from a mood disorder. Clinicians may reach different conclusions, depending on when they conduct assessments relative to the patient’s entry into treatment.⁸
Next, consider the nature of certain mental illnesses, which are established as risk factors for addiction, themselves. Depression and anxiety have been shown to contribute to SUD, most commonly, when people suffering from severe, mild, or even subclinical mental disorders turn to drugs to self-medicate. 
Self-medication is never wise, but many who go that direction find some sort of temporary relief. In the long run, however, these patients can inadvertently develop an addiction to the substances and consequences to their health and well-being. 

Sometimes mental disorders may foster SUDs. 

It has been suggested that psychiatric disorders and SUDs may increase the risk for the other. Many individuals with SUDs claim they use drugs and alcohol to combat unwanted moods. The substances may initially minimize or moderate the symptoms of depression and anxiety, but withdrawal and chronic abuse typically exacerbate mood degradation, leading to increasing abuse and ultimately, dependence.⁹
On the provider side of the fence, physicians who are attempting to treat persistent depression and anxiety may not be aware of coinciding SUDs because the patient never mentions it. If medical assistance is sought, the patient may see a physician for each of the disorders, and there’s often no reason for either of them to screen for the other. When a patient sees one provider for SUD and another for mental illness, the two conditions can become mutually exclusive, and either could become invisible to both of providers.
Even when the physician is aware of all the symptoms of overlapping conditions, diagnosis and treatment of SUDs and mental illnesses can be complicated because it may be difficult to sort out the symptoms. Patients who suffer from both addiction and a mental illness often exhibit symptoms that are more persistent, severe, and resistant to treatment compared with patients who have either disorder alone.¹⁰
Once the physician is aware of mental illness coexisting with SUD, s/he may better prescribe medication that will work without irritating the other disorder. In fact, integrated treatment for drug use disorders and mental illness has been found to be consistently superior when compared with separate treatment of each diagnosis.¹¹  

The Threat of Addiction is Still a Factor

The threat of addiction is still a factor when a healthcare provider sets out to prescribe medication for anxiety and depression because some medicines can become habit-forming. Without full patient records, the provider may not be aware of all the side effects that the patient will experience. There are plenty of medications that may work well for patients suffering from psychiatric disorders, but Crossroads knows to abstain from prescribing them to avoid patient dependence. Some antidepressants, such as benzodiazepines (also known as benzos) can be especially dangerous for patients in recovery for an SUD.  For example, benzos make up a class of medication that, when mixed with opioids, may suppress breathing and lead to an overdose. A recent study showed that people concurrently using opioids and benzos are at higher risk of visiting the emergency department or being admitted to a hospital for a drug-related emergency. ¹²
This is one of the medications we can avoid prescribing because we’re aware that the threat of addiction may be higher in SUD patients. 
By offering treatment for SUDs and some psychiatric disorders under the same roof, Crossroads is working to eliminate any confusion that may result when a patient seeks treatment for each separate disorder.  There are many medicines a provider may prescribe, but each one works differently and can have different outcomes in different patients. Crossroads prescribes antidepressants that are the least likely to cause addiction in patients with SUD.
The medications that are less addictive and most commonly prescribed are known as SSRIs (selective serotonin reuptake inhibitors), including Lexapro, Prozac, Zoloft, Paxil, and Celexa. Another class, the SNRIs (serotonin/norepinephrine reuptake inhibitors) includes Effexor and Cymbalta – which treat depression and anxiety disorders. Finally, there is Wellbutrin, an SNRI-like medication that also helps with the cessation of smoking. Each of these classes pose little to no threat to those taking opioids or battling SUDs. 
Unfortunately, overcoming all the challenges already described still doesn’t mean that patients receive adequate help with mental illness. A shortage of providers in the US can make treatment very hard to come by for a majority of Americans – across all socio-economic groups. Roughly 60% of US counties, including 80% of all rural counties, face the grim reality that they lack even a single psychiatrist. But it’s not just the rural areas that are feeling the pinch; across the US, it’s calculated that there are merely 11.5 psychiatrists for every 100,000 Americans.¹³ 

Crossroads is Making it Easier for Patients to Find the Help They Need

By offering treatment for anxiety and depression where our patients are already seeking help for SUD, Crossroads is making it easier for patients to find the treatment they need. Founded upon the view that all people – including those in rural areas – deserve convenient access to the highest quality behavioral healthcare, Crossroads is continuing to add services for mental disorders in more of our centers.
“There are lots of reasons people don’t seek help for mental illness, but one of the biggest barriers is simply finding treatment. At Crossroads, we want to help patients overcome that barrier by offering treatment for mild to moderate mental health conditions via telehealth—which really makes it more convenient,” says Dr. Trey Causey, Crossroads Chief Medical Officer and board-certified general psychiatrist and addiction psychiatrist.
With all the obstacles that can stand in the way of obtaining proper treatment for SUDs as well as anxiety and depression, it’s easy to see that there is a huge need to simplify the process. By bringing treatment for SUD and mental health disorders under the same roof, Crossroads is well on its way to achieving that in the communities we serve. 

1 “Part 1: The Connection between Substance Use Disorders and Mental Illness.” National Institutes of Health, U.S. Department of Health and Human Services, 13 Apr. 2021, https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness?msclkid=86d90cd8ba7411ec9403ff8e99a9d9d0. 

2 Magidson JF, Liu S-M, Lejuez CW, Blanco C. Comparison of the Course of Substance Use Disorders among Individuals with and without Generalized Anxiety Disorder in a Nationally Representative Sample. J Psychiatr Res. 2012;46(5):659-666. doi:10.1016/j.jpsychires.2012.02.011.

3 “Part 1: The Connection between Substance Use Disorders and Mental Illness.” National Institutes of Health, U.S. Department of Health and Human Services, 13 Apr. 2021, https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness?msclkid=86d90cd8ba7411ec9403ff8e99a9d9d0. 

4 “Facts & Statistics: Anxiety and Depression Association of America, ADAA.” Facts & Statistics | Anxiety and Depression Association of America, ADAA, adaa.org/understanding-anxiety/facts-statistics. 

5 “Depression: Anxiety and Depression Association of America, ADAA.” Depression | Anxiety and Depression Association of America, ADAA, Anxiety and Depression Association of America, adaa.org/understanding-anxiety/depression. 

6 “Part 1: The Connection between Substance Use Disorders and Mental Illness.” National Institutes of Health, U.S. Department of Health and Human Services, 13 Apr. 2021, https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness?msclkid=86d90cd8ba7411ec9403ff8e99a9d9d0

7 “Part 1: The Connection between Substance Use Disorders and Mental Illness.” National Institutes of Health, U.S. Department of Health and Human Services, 13 Apr. 2021, https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness?msclkid=86d90cd8ba7411ec9403ff8e99a9d9d0

8 Quello SB, Brady KT, Sonne SC. Mood disorders and substance use disorder: a complex comorbidity. Sci Pract Perspect. 2005;3(1):13-21. doi:10.1151/spp053113

9 Quello SB, Brady KT, Sonne SC. Mood disorders and substance use disorder: a complex comorbidity. Sci Pract Perspect. 2005;3(1):13-21. doi:10.1151/spp053113

10 “Part 1: The Connection between Substance Use Disorders and Mental Illness.” National Institutes of Health, U.S. Department of Health and Human Services, 13 Apr. 2021, https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness?msclkid=86d90cd8ba7411ec9403ff8e99a9d9d0

11 Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24. doi:10.1016/j.addbeh.2011.09.010.

12 Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ. 2017;356:j760.

13 Harrar, Sari. “The Silent Shortage – New American Economy.” Inside America’s Psychiatrist Shortage, PSYCOM, 2 Feb. 2022, http://research.newamericaneconomy.org/wp-content/uploads/2017/10/NAE_PsychiatristShortage_V6-1.pdf.