Hi, everybody. My name is Antoine Dewey. I'm a professor of psychiatric medicine at the University of Pittsburgh School of Medicine. So what I will be discussing today is the co-occurring psychiatric substance use disorders. These are my disclosures and research grants from NIDA and MH, SAMHSA, AFSP, CDC, and also I get royalties for academic books published for UD, PSI Publishing, Springer, as well as Oakstone CME. Okay, the learning objectives of the lecture. At the end of this presentation, the participants will be able to summarize the prevalence of co-occurring disorders. I'm going to refer to them as CODs, co-occurring psychiatric substance use disorders, explain the theories of CODs, identify the overrepresented psychiatric disorders in these CODs, delineate evidence-based principles of successful assessment, evaluation, and treatment, and translate these evidence-based practices and principles into applications into the real world practice. And I will also review the psychosocial as well as pharmacological interventions for patients who have CODs. So how we define a co-occurring disorder. And so what we're talking about is this simultaneous co-occurrence of psychiatric as well as substance use disorders. I mean, we used to call them dual diagnosis. We used to call them co-morbidities, but it's the simultaneous presence of at least two different diagnosable conditions. One of which is definitely substance use disorders, could be alcohol use disorders, and the other one is either depression, anxiety, bipolar disorder, trauma-related disorders, for example. Half of those who experience a psychiatric illness during their lives will also experience substance use disorders and vice versa. So we talk about one out of two people who have a substance use disorder throughout their lives would experience a psychiatric disorder simultaneously and vice versa. Over 60% of adolescents in community-based substance use disorder treatment programs also meet the criteria for another psychiatric disorder. And if you look at the data from the large nationally representative sample, people with mental personality and substance use disorders, so people with psychiatric personality disorder, which are psychiatrists too, and SUD, are, they were in fact from the data, at increased risk for non-medical use of prescriptions, of fluids. And this is very crucial, you know, because that changes the whole basic treatment approach. So these are really old studies. You talk about the study from 1990, but it's still very valid, you know, and it's really different. And so this is a sample of 10,000 adult patients, and we looked at the comorbidity of substance use and psychiatric disorders. 13.5% have an alcohol use disorder. And of those, 36% also have a psychiatric disorder. 6% had a drug use disorder. Of those, half of them, basically, 53% had a psychiatric disorder. And the people who have a psychiatric disorder are 22.5%. Of those, almost 29% had an alcohol use disorder. The bottom line is, whichever way you look at it, the combination of alcohol use, drug use disorders, and psychiatric disorders is really very high. The rates are very high. And the comorbidity is highly prevalent. So here, what are the, this is from the two studies of prevalence rates in addiction treatment settings. It shows the similar findings. People who have substance use disorders are also likely to have mood and anxiety disorders. Look at the percentages here. I mean, that depends on methodology here of the studies, but very high percentages of mood disorders, anxiety disorders, PTSD, which is now under the umbrella of tolerated disorders, antisocial personality disorder, borderline personality disorder, and schizophrenia. So the top, basically, if you think about it, the top ones, top psychiatric disorders that are co-occurring with substance use disorders are mood disorders, anxiety disorders, but also look at the personality disorders that are very highly prevalent, as well as really the trauma-related disorders. This is from SAMHSA 2021 data among adults age 18 or older. And this is a past year substance use disorders, any mental illness, AMI, and serious mental illness. When we're talking about serious mental illness, we're talking about psychotic disorders, severe bipolar disorders. And this is what mostly are the severe serious mental illness, but it could include also refractory depression, too. Take a look here at the numbers. You know, the numbers here are 73, if you look at the key substance use and mental health indicators from 2020, basically, in fact. This is the NASDA, the National Survey on Drug Use and Health, and 73.8 million adults had either substance use disorders or any mental illness. Take a look at really here the circles. So you have 17 million adults who had SUD and AMI, who are the co-currents, 20.9 million had just SUD, no AMI, 37.9 million had SUD, and 35.9 million had AMI without SUD, and 52.9 million adults had any mental illness. The bottom line is, if you look at the middle, the green piece, the adult that had SUD and AMI, you have 17 million out of 73.8 million adults who had either SUD or AMI. So I mean, this is really a pretty big percentage here. Take a look at this one, too. You know, these are most recent data that we have, you know, and interestingly enough, if you look at the adults who have SUD and severe serious mental illness, 6.4 million. The people who had serious mental illness without SUD, 7.7 million. But I mean, obviously the conversions, you know, the purple color, you know, it's still very highly significant. So again, these really two conditions, substance use disorders, as well as serious mental illness or any mental illness, they are intertwined, they are so connected to each other. So which means it's very likely that you see somebody with a substance use disorder who does not have any psychiatric, even symptoms, maybe some of the symptoms would end up meeting the criteria for a psychiatric disorder. Some of them don't, and vice versa. People who present with serious mental illness or any mental illness, you know, clinical features or representations or symptoms, they could end up also with some sort of substance use behaviors that could meet either substance use disorder or lower level of substance use. The overlap, as you can see, is very pronounced, mostly with serious mental illness. Around one in four individuals, serious mental illness also have an SUD. So to keep that in mind, and the data is really has not much changed for years, which is really very significant. And again, that non-Aphrodite, and I'm going to talk about it in details, how does it affect the treatment eventually? And there's always the question of, obviously, and we'll talk about the theories of why they are so common, the co-occurring disorders, is the issue of the chicken or the egg, but it doesn't matter. And I'm going to talk about it in a bit. So which comes first, the chicken or the egg? That doesn't matter. Once they are together, they need to be treated together simultaneously. And it doesn't matter, of course, because how you treat one is going to affect the other one, which means the combination of two disorders to begin with, and this is a point of clear agreement that if the two disorders are combined, it's generally more serious with more negative consequences than either disorder alone. The CODs tend to have more severe and tend to be more severe than just one disorder by itself and have a negative impact on the quality of life. And when the SUD happen with mental illness together, the course of each problem area is worsened, which is very crucial, which speaks to the importance of treating simultaneously. If you treat one, ignore the other one, one is going to affect the other one in a negative way. And the presence of co-occurring SUD may affect symptomatology in people diagnosed with severe mental illness. So which means if somebody has psychotic disorders and they start using any substances, whether cannabis or stimulants, you know, it's going to affect, it's going to worsen and affect in a negative way the symptoms of the psychosis. So what are really the factors that affect the functioning and prognosis of individuals with CODs? If the symptoms are more acute, that can really lead to the deterioration of the two disorders in a way and worsening of the clinical presentation, but also worsening of the prognosis. And if it becomes also chronic and severe, you know, I mean the clinical manifestations, you know, that's going to affect the ability of people to function and it's going to affect the prognosis for the long run. As I mentioned, alcohol or drug use, any alcohol or drug use could be potentially problematic. It can affect also the co-occurring disorders, can affect physical health, cognitive functioning, as well as the recovery capital. People are going to have to recover from both conditions to be in recovery and the recovery capital is going to be affected if one condition is not really addressed and treated as aggressively as the other condition. So I mean, this is really crucial, you know, and clearly here, the bottom line is treating those with co-occurring disorders with CODs is certainly more challenging and more problematic could be and then treating people with a single disorder, that's the bottom line. So the question is that why they are so common, you know, what are the theories here? There are a lot of theories that have been really addressed, you know, and explored. Let's put it this way. The first theory, you know, which is really one of the most popular explanations for the CODs, and you've heard about it, is the self-medication hypothesis. The mass self-medication hypothesis that people are using alcohol, tobacco, or other drugs in an attempt to manage their psychiatric problems, meaning to numb how they feel or to self-medicate. And the explanation is really makes sense in a way when you think about it. And because you have a lot of people tell you, oh, I really smoke pot because it helps me relax and forget my problems and numbs my feelings, that I wouldn't have to deal with the grief and all this. You know, and this is important from the research that we have. It doesn't necessarily support, you know, such clear association between the patient's symptoms and the type of substances used, which means that this whole idea of there is a drug of choice does not exist. That concept is very pejorative, in fact, and the drugs that people use can be influenced by peers. The person's use can persist, in fact, despite fluctuations in symptoms over time. And one thing I want to mention to you here, it's not necessary that the drug actually yields the effect that people are seeking, the desired effect, but only that the person believes it does so. If the person believes if smoking pot is going to make them feel numb or it's not going to make them feel relaxed, most likely this is the reason they're going to use pot. So in a sense, like a self-fulfilling prophecy here. And when we're talking about self-medication hypothesis, you know, it's important to really mention one thing that sometimes, you know, people are really have a tendency, you know, to drink heavily. You know, may remember, you know, that the earlier stimulant effects that alcohol has and they might sometimes forget also the select, forget that depression rebound that occurs late with high doses of alcohol. So again, you can think, you know, of it as a self-medication hypothesis, you know, that explains it, but also there's a tendency for people to really remember the immediate effect, but also forget the effects later on. So which means, you know, that when people kind of use these substances to numb certain really psychiatric emotions, you know, psychiatric symptoms or emotions, you know, they might not even remember that they did it for that reason. And all they would be focused on is the positive effects. So this is the first theory, the self-medication theory, you know, and hypothesis. Second one is the sensitivity to alcohol and other drugs. And this is important. This is what we call like patients who have CODs, they might have what we call like a biological diathesis, which is a vulnerability that increases the likelihood for developing a psychiatric disorder. I mean here you're talking about an interaction between gene expression, person's environment, certain stressors, all different things you know that eventually lead to that vulnerability to experiencing a full-blown psychiatric disorder. And it's been hypothesized that the people who would have who have that such a psychiatric vulnerability you know may be very sensitive to the effects of certain drugs. Even a small use even a small use of the drug might be considered really low or moderate use that can trigger the psychiatric symptoms. We're not clear about that vulnerability where it's coming from and how it's understood. But another really good example that we can look at is a person who experiences the first psychiatric episode during or after taking you know a psychedelic drug like a hallucinogenic drug. So the vulnerability was there and what ends up happening the symptoms were triggered by the drug experience. And in turn it causes what we call the kindling you know you see it you know with the mood stabilizer sometimes. You know that experiencing a first episode places the person more at increased risk for further episodes and could be more severe episodes. You know and this could be really true in depression, alcohol use, alcohol withdrawal, induced seizure. So again this is something that also see for example in bipolar disorder. So again that is this kind of really the essential idea here from the sensitive is that you know that the substance used triggers the expression of some sort of a genetic vulnerability to psychiatric disorder. So is it like a clear? Not totally clear but this is one of the hypotheses that we know. And other hypotheses are the common factors. Under the common factors there are four that I want to mention. I already talked about the genetic vulnerability but the genetic vulnerability is to both the substance use as well as psychiatric disorder. And this is very important to keep in mind. The vulnerability could be also vary from one person to another. You know even they develop the same disorder but it could be really you know a different type of vulnerability. The other thing is basically the neurocognitive factors. What are the neurocognitive factors? Because under genetic vulnerability also there are other factors. Familiar factors, environmental factors, social factors. I'm going to talk about it here. But also there is a factor of the neurocognition. And what I'm referring to is a neurocognitive impairment of the ability to self-regulate. And this is really important to keep in mind. And usually when there is an inability to self-regulate you know that could really increase the risk for antisocial personality disorders, psychosis, substance use disorders. So again this is one of the factors and theories that have been looked at. Another thing that has been proposed is the environmental factors such as a history of trauma. That's very important to keep in mind. History of IPV, history of poverty, deprivation. It can predispose people to you know developing psychiatric as well as substance use disorders. And this is a shared common factor here. You know and another kind of really importance you know to that factor was the common factor is the underlying emotional blunting that may be another that common factor that underlies childhood conduct disorders and antisocial personality disorder. Again these are more theoretical. And as I mentioned you know the genetic vulnerability is different from the genetic factors. The research does not support much of the genetic factors as an explanation for the co-occurrence of substance use and psychiatric disorders. And I mentioned you know the developmental aspect. So the question is you have all these theories. Does one of them hold really exactly you know the understanding of the co-occurrence of psychiatric and substance use disorders? Not really. It could be a combination of both. There is no one theory that explains you know the CODs. There could be multiple theories, multiple common factors you know that could really explain it. So what are the overrepresented psychiatric disorders in the co-occurrence you know in the CODs? First and foremost mood disorders. Most common co-occurrence and concomitance is substance use with mood disorders. Mostly the depression and obviously also bipolar disorders. Two majorly very important. We have to be very careful about not always assuming you know if they are happening in the context of people using substances that you know mood disturbances are really the related or secondary substance use problem. So always remembering that you know and one of the things that I want to mention here that is very very crucial as a co-occurrence. The co-occurrence of the depression, bipolar disorder in particular and substance use disorders leads to one of the highest statistic risk for suicide. So suicide risk goes up when there's a combination of mood disorders and alcohol excuse me use disorder or drug users but mostly with the alcohol. So keeping that in mind. Anxiety disorders come next. They are the among the most common co-occurring conditions like mood disorders and they can be diagnosed very much in very high prevalence like 20 to 30 percent you know and people will have alcohol use disorder. And again do not assume that if people have anxiety disorders they are just related to the substance use. And the other really anxiety disorders or the trauma related disorders you know that can co-occur with addictions you know similar to really childhood you know abuse and traumatic experiences. And obviously the PTSD is a big one too. And again looking at the theory of the self-medication you know sometimes people really end up really using you know to really self-medicate here to escape from that severe anxiety that they are experiencing. And we need to be careful here with the benzodiazepine. Benzodiazepine could be initially used you know to help relieve that anxiety but eventually that can make it much worse and people can get very easily addicted to the benzodiazepine. So the third condition that is over-represented is schizophrenia and other psychotic disorders. And as you know very well any thought disorders there has been a lot of debate over the cannabis predisposing people the use of cannabis predisposing people increasing vulnerability to developing psychosis and schizophrenia. And there is no causality is not totally clear you know but the bottom line is it is also a lot of people in fact you know who have psychotic disorder that's schizophrenia they have a tendency to still use substances particularly the cannabis you know which is really highly prevalent in that population. Personality disorders and we're referring to cluster B you know they have a very high incidence of comitant substance use disorders and we're referring to two major personalities the antisocial as well as the borderline personality disorders. And a lot of these individuals they display impulsive behaviors and when combined with substance use the impulsive behaviors can get much worse even. And we know very well so you know that these kind of also personality disorder are associated with the emotional dysregulation and people can engage a lot of risky behaviors and some of these risky behaviors if they were to be using any substances they could be using you know intravenous you know substances. So the question is that could be avoiding what can we do to avoid misdiagnosis and again this is really crucial that's obviously engaging the patient and getting the story but also not assuming right away that the symptoms the psychotic symptoms are related to the substance use itself. And there is always the idea that well let's wait until the withdrawal symptoms are dissipating and then we can re-evaluate clearly and that is true at the same time while people going withdrawal and have psychiatric symptoms and you know they could really be at risk for suicide, they could be at risk for impulsive behaviors so the treatment has to be initiated very early on and we need to be very careful about not delaying treatment because of our own assumptions. And one of the things that is important meeting the agnostic criteria for particular disorder prior to the onset of substance use let's keep that in mind is a strong evidence for an independent non-substance related psychiatric disorders. Let's say somebody who has a severe panic disorder for years and then they start drinking and the panic symptoms start getting worse but they have a prior you know you know panic disorder you know that kind of in a way is considered as an independent a primary you know I mean we don't use that classification anymore but primary versus secondary you know diagnosis you know which means you know that the the psychiatric disorder was prior to really the substance use. I want to mention here some of the drug effects that mimic psychiatric disorders. Alcohol you know like intoxication or acute withdrawal or protracted withdrawal like people can present when they are acutely intoxicated euphoric mood liability inhibition when they are going through acute withdrawal they are agitated hallucinating could be delirious they could have sleep problems so again they can mimic a lot of the psychiatric manic depressive symptoms. Stimulants they can mimic also psychiatric disorders you know they can mimic you know the paranoia the impulsivity the grandiosity so manic psychotic stuff hallucinogenics you know that they can really lead to this dissociation hallucinations anxiety paranoia delusions delirium cannabis cannabis also the same thing can mimic a lot of psychiatric you know symptoms could be like euphoria could be agitation could be paranoia could be you know hallucinations could be depression they used to call it the amotivation syndrome. Inhalants it mimics psychiatric disorders particularly cognitive problems euphoria agitation anxiety psychotic symptoms the sedatives as we as you know they can through intoxication acute withdrawal or protracted withdrawal people can end up with a euphoria mood liability anxiety depression depersonalization derealization opioids again euphoria being pre-depressed apathetic and and also anxiety sleep disturbances so again we need to speak with getting a better understanding of what how all these substances can mimic psychiatric disorders. So screening the screening is really kind of a very interesting part you know and usually we look at with the particular symptoms that can match you know with diagnosis but also the same thing you know when we did the screening for substance use you know we do the screening for psychotic disorders you know issues of sensitivity specificity there are some particular screening tools that we use not really very commonly in clinical practice and but the question is has been really what the predictive value is you know and but again it's just all going to depend on clinical judgment you know how we integrate the screening which means the screening for both is really we need to always each kind of of the disorder should used to be it should be considered within the context of the other and a comprehensive screening process would incorporate other domains and potential service needs and we talked about the multi-dimensional aspect multi-dimensional aspect housing physical health trauma victimization all these aspects because the consequences are very significant and negative. This whole idea of delaying assessment evaluation of a patient because we want to wait for some full sobriety for 30 days is not acceptable we can't wait we can't wait we have to treat and we cannot delay because you know things can happen within that short period of time that can have things I'll talk about behaviors that patients can engage in that can have very serious consequences. There is no arbitrary barrier to the initiation of screening evaluation or psychopharmacological intervention based on the substance levels of the duration of sobriety. And again the integrated and longitudinal evaluation has to be looked at of the persistent mental health problems as well as substance use and we need to understand also how they overlap also with each other evaluating peers of 30 days longer you know in the history when the patient was either abstinence or using substances below the threshold that would affect the symptoms you know so we need to always keep in mind that you know what role you know the substances could have played in that whole process you know and if people are really kind of they could still be using here and there but their psychiatric symptoms can be still very significant even beyond the 30 days. So the assessment will include engaging the patient using motivation strategies, cultural humility, screening for and detecting it, determining diagnosis, functional impairment, disability, again motivation for change we talked about it in the screening and evaluation like where are they read you know where are they in terms of the readiness for change sometimes you know patient would show up and tell you oh I want to treat my depression, but I don't care much about my drinking. So you will need to figure that out. And there is what we call the determining the quadrant and locus of responsibility. The quadrant model was really conceptualized subgroup of individuals in disorders to get a better understanding of the severity of the illness. So you have psychiatric severity, substance use severity, low and high, and you have, you know, level one low, you know, when it comes to psychiatric severity, substance use severity. Level two is high. When it comes to low substance use severity, high psychiatric severity. High psychiatric severity will go with quadrant number four with high substance use severity. Or if the substance use severity is low, oh, sorry, high, but the psychiatric disorder severity is low, it's a quadrant three. Again, this is kind of a more to get some better sense of where patient fit in, how much is more significant in terms of the severity of the psychosis versus the substance use disorders. Always remembering, determining the level of care, identifying strengths, resilience, value system, cultural needs, involving concerns and others, and always individualizing, forming addiction treatment based on individualized treatment plan. I mentioned about the quadrant model that is not as used as much. The bottom line now that has been well-established as the approach is the integrated model of treatment. Integrated model of treatment, meaning, you know, treating the two conditions simultaneously. The question is gonna be, is it gonna be happening in the same place, or, you know, ideally it should be in what we call like a dual recovery setting, which our clinic is about. Or, you know, it can be done also, you know, if it's disjointed, can be done by two providers as long as they communicate with each other about really how the patient is doing and how their two disorders really interact with each other. I gave an example here of a 28-year-old woman who went through addiction treatment where she was assessed as having alcohol abuse disorder. Six months later, she's been diagnosed with major depression disorder, prescribed medications by her family doctor. At the treatment facility, it was recommended that she be reassessed and treated at a mental health clinic located nearby in town. What model of treatment does this scenario present? So obviously integrated treatment model means, you know, treating both. The single model is that treating one disorder. Sequential, starting with one, continue with the next. Parallel is basically in two separate places. So what ended up happening is with this patient, think about it, you know, that they wanted to treat her for the mental health clinic, but the substance use is not, the alcohol use is not addressed. So in a sense, what happened is that more of a sequential, like she got started, you know, with treatment, with alcohol, and then diagnosed with major depression and referred for the major depression. So really, optimally, you know, it has to be an integrated model. In fact, she received a sequential. These are the quadrants of care that I was mentioning. You know, that the low severity of substance use to high and the low severity of psychiatric disorders to high. Why integrated treatment? And we know very well, you know, that integrated treatment provides the best prognosis. And what is very depressing about it, if you think about it, is in 2021 of those receiving treatment, only 6%. These are people who have COD, who have like a co-occurring disorders. Only 6% received integrated care. That's really demonizing, if you think about it. The high rate is there. That's why we need to treat it in an integrated way. The high rate of substance use and psychiatric disorders. The comorbidities, as I already mentioned, affect the course and prognosis of both individual psychiatric and substance use. And individuals experience poorer outcome compared to having one disorder. And they could have also significant cognitive impairment that can affect their therapeutic work and outcomes of the conditions. So there is a higher service utilization and increased service cost. We know, unfortunately, you know, the treatment programs do not train their AD staff to do this integrated and simultaneous care. And, but we know very well that it provides a lot of saving in the long run and retain people in treatment. And retain people in treatment. Let's kind of think about what are those practices that we're talking about in an integrated care model? Those practices are motivational interviewing, which Samia talked about that, the strengthening the person's motivation for change, motivation incentivizing people coming to treatment, presenting with negative urine drug screen and all this, and relapse prevention counseling, working on both relapse prevention counseling for the psychiatric disorder as well as substance use disorder and the dual recovery counseling, which means counseling, type of counseling that would integrate both approaches. There is an approach called the assertive community treatment you know, that is really, you know, more kind of has some sort of an intensity to it, but incorporates a lot of the elements that I mentioned, but it's really kind of also helping empowering people, you know, to be the kind of, be also out in the community if it's possible to help people who have more severe disorders. And it relies a lot also on case management, you know, and other really resources. In fact, it takes what we call treatment to the person. This is from, you know, a study that was done by a Yale group years back on what they call integrated care, the three-legged stool, and you present it to the patients, tell them that if you were to think of yourself, you know, your struggles, your illness as a co-occurring disorder, you know, as a three-legged stool, you know, what would you, what would be the three legs present? One, absence from alcoholism and drugs. Second, adherence to the medications. Three, engagement, treatment, and mutual support group, AA and A, or do a recovery, and medical care. So if one of these two, sorry, one of these legs are not there, what's going to happen to the stool? Tip over. So, I mean, it helps patients, you know, really see the importance of working on all these pieces. So these are the integrated component, the components of the integrated approach. I already mentioned a lot of them, integration, comprehensiveness, assertiveness, reduction of negative consequences. We need to think about it for the long term. Multiple psychotherapeutic modalities, I've already explained. It has to be motivationally based where the patients are. The benefits of the integrated model reduce the need for coordination, reduce frustration for patients, emphasizing supporting autonomy and shared decision-making, involving concerned significant others, crucial for family members. Transparent practices help everyone involved share responsibility. Patients are empowered to manage their own illness, their own recovery. You facilitate and guide the patients and their families, and concerns signify more options to choose from in treatment, more ability for self-management, higher satisfaction rates, and higher rates of retention in treatment, which is what we're looking for. So these are the assumptions here about the interactions of co-occurring disorders, that it does not, when disorder is not necessarily presented as primary, there isn't necessarily a causal relationship between CODs. I mentioned that, you know, that's a very tough answer. I gave the example of cannabis and cicatrania. These are co-occurring conditions that need to be treated simultaneously. Evidence-based practices, I already mentioned a lot of those. Motivation to viewing and adaptation, motivation to enhancement therapy, CBT, very crucial to incorporate, and it's relapse prevention counseling, and integrates also to do a recovery counseling. 12-step facilitation, which is an individual therapy, which is a combination of both. 12-step facilitation, which is an individual therapy to help people engage in 12-step programs, but also the particular 12-step programs are the dual recovery anonymous. Double trouble, they call it. They are really not as really frequent in the community as you would like to see them, but people would seek, you know, what could the DRA, you know, and that, you know, and they can, they have the same principles as any 12-step programs. The family intervention, I'll put a question mark. They could be basically an add-on, you know, and depending on the context, clinical context, as well as behavioral comfort therapy, and obviously the pharmacotherapy is very important piece, whether we're treating the substance use or psychiatric disorders or the combination. The psychosocial treatment that has really been very, very effective and has a very robust support is the impact of MR and motivation to healing. Keeps people retained in treatment, but other things too can be very helpful. The highly structured therapy program like IOP, intensive outpatient program, care management services, recovery specialists, behavioral therapies, I talked about the incentives, you know, and intensity of treatment must be increased for severe comorbid conditions, you know, so that's why you need to really kind of match what people are struggling with, the appropriate treatment. And they might need some patients, but need more intensive treatment than others. Very quickly, just want to mention before I move on to the pharmacotherapy, that the case for PTSD and SUD, which is very common occurrence, nearly half of people who have PTSD, they meet criteria for the SUD, and individuals with PTSD are five times more likely to have SUD compared to those without PTSD. So this is very crucial, you know, occurrence. There's an integrated model of treatment that need to be approached. If you reduce the PTSD symptoms, they are more likely to reduce the substance use rather than reverse. So if you reduce the substance use, does not necessarily reduce PTSD symptoms. There are different types of psychosocial approaches, trauma-based, of exposure-focused, like the example of the COPE strategy. The non-trauma-focused, which is seeking safety, Nezhevets, you know, conceptualize that, and integrating the CBT, cognitive behavior therapy, into it. The COPE is a concurrent treatment of the PTSD and substance use. They use, you know, an approach of long exposure. Unfortunately, pharmacological interventions in that kind of context are limited, but I mean, it can be definitely used. In terms of pharmacotherapy, these are some of the medications that have been used. You know, to treat co-occurring disorders, antidepressants, anxiolytics, stimulants, antipsychotics, mood stabilizers. There is a big issue of the medication non-adherence. You know, and we need to understand that this is a serious problem that needs to be continually addressed and monitored because patients have a tendency to discontinue the medications. And you address the ambivalence, you know, which means, you know, as I discussed, you know, in the previous lectures, ambivalence, you know, about taking medication, about staying in treatment, and this has to be addressed. What do we know? What do we have? In terms of the antidepressants, you know, that are really effective at reducing, you know, the depressive and anxiety symptoms, for example. But the ones that are prescribed to improve substance-related symptoms are either not really highly effective or involve some risks. So the focus of the antidepressant is more the mood and anxiety symptoms. What we have in terms of studies is a combination of sertraline and naltrexone that reduce the drinking, and people have depression, alcohol use disorders. In our clinic, we did a combination of fluoxetine and naltrexone and also addressed AUD, alcohol use disorder, and MDD, and it reduces the depressive disorders. And as a result of that, also, we see a decrease. When you add the naltrexone, you see a decrease in the alcohol use. Mirtazapine has been also uniquely appearing to be improving depression and to function as some sort of an anti-craving agent in patients who have AUD and MDD, and particularly adults and youth also, and young adults, you know, and adolescents, late adolescents. The second-generation antipsychotics are more effective for treatment of schizophrenia context, you know, and of the comorbid substance use disorders. The ones that have been used and have the most evidence are clozapine, lenzepine, or risperidone. In fact, clozapine appears to be most effective of the antipsychotics for reducing alcohol, cocaine, and cannabis use among patients with schizophrenia. Some medications were explored to address anti-craving, such as baclofen, vigabatrin, and I'm talking about anti-craving for stimulant, modafinil, and methamphetamine, not FDA approved, not FDA approved. I want to be very clear about that. And there's a pyramid for cocaine that has been non-FDA approved. Mirtazapine and lenzepine, non-FDA approved. Mirtazapine and bupropion, which is well, beautiful, methamphetamine. We did a study on valproate acid, you know, that to add as a treatment, you know, to, that decreases heavy drinking in people who have comorbid bipolar disorder, AOD. So that would be kind of a good option, valproate, you know, depakote, you know, to treat the heavy drinking in patients who have a comorbid bipolar disorder, AOD. And also they control the bipolar disorder symptoms. Again, non-FDA approved. None of the ones that I mentioned to you. And there is a potential clinical utility of valproate, as I mentioned, in bipolar disorder, co-occurring with alcohol use disorder. When you think of recovery, you need to think about something beyond the diagnosis, beyond the disorders, meaning, you know, what does it mean to the person? What matters? Reclaiming the self, empowering people to self-regulation, management of their illness. Always think about the importance of mutual support groups. And I want to leave it as a note of optimism. And the note of optimism is that people do get better. These conditions are very highly treatable and people improve and really considerably, in fact. They improve considerably and they function much better if they receive the best treatment. And the best treatment that we're talking about is the integrated care. These are the references. Thank you.

psychiatric medicine

substance use disorders

co-occurring disorders

adolescents

comorbidity

integrated care

evidence-based practices

motivational interviewing

cognitive behavioral therapy