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Comorbidity of Anxiety and Depression with Substance Use Disorders

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Abstract

The comorbidity of substance use disorders (SUDs) with anxiety and depression is the focus of substantial research attention and approached from myriad perspectives. This chapter focuses on the resultant complex research literature, first providing an overview of epidemiologic studies that have examined the prevalence of co-occurrence of SUDs (including alcohol and other drug use disorders) with anxiety and depressive disorders, as well as clinical correlates of these forms of comorbidity. Next, theoretical models of the onset and maintenance of emotional disorder–SUD comorbidity are considered, followed by a review of various types of studies evaluating these theoretical models (studies focusing on order-of-onset, the independent versus substance-induced disorder distinction, self-reported motives for use, genetic epidemiology, and experimental studies). Distinctions and commonalities between anxiety–SUD associations and depression–SUD associations are examined throughout. The chapter concludes by examining treatment implications of this comorbidity and suggests future directions for this burgeoning field.
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... For example, SGMY may turn to substance use as a means of coping with the stigma associated with their marginalized gender and sexual identities, especially if they have the added burdens of homelessness and/or HIV-positive status (Heerde & Hemphill, 2016;Smit et al., 2012). Unfortunately, the use of substances may also increase depression by triggering a depressive episode after the effects of the substances wear off or in the aftermath of bad decisions made during substance use (Stewart et al., 2014;Washton & Zweben, 2022). ...
... In contrast, the association between depression and cannabis use is more likely bidirectional: Cannabis use predicts depression (Bahorik et al., 2017(Bahorik et al., , 2018, and depression predicts cannabis use (Bertholet et al., 2018;Tyler et al., 2019). The association between depression and substance use could also be the result of trauma (Stewart et al., 2014;Washton & Zweben, 2022). ...
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Objective: Trauma, depressive symptoms, and the use of alcohol and drugs are common among youth, especially those with marginalized racial/ethnic identities, sexual and gender minority youth (SGMY), and those with low socioeconomic status, homelessness, and HIV-positive status. However, most research on trauma, depression, and substance use among such youth is cross-sectional. This article examines these patterns over time. Method: Participants were youth with multiple life challenges (N = 1,728) recruited from 13 community-based agencies and health centers in Los Angeles, CA, and New Orleans, LA, and reassessed twice at 4-month intervals over 8 months (follow-up > 70%). Youth were predominantly Black, Latiné, and SGMY, with an average age of 21 years (range 12–24). We analyzed the association between trauma, depression, and substance use using a Bayesian approach to latent growth curve modeling. Results: Trauma had a robust, positive association with depressive symptoms and substance use, although this association differed depending on whether alcohol or cannabis use was examined. Higher levels of trauma were also associated with a slower decline in depressive symptoms over time. Conclusion: Study findings highlight the longitudinal association between trauma and both depression and substance use. This suggests the potential utility of trauma-focused interventions among vulnerable youth with one or both of these issues.
... Reflect on progress, prepare for termination Identify long-and short-term goals for post-treatment Psychoeducation and planning for potential setbacks Note. Table 2.1 reproduced with permission from Stapinski et al. (2015) evidence suggesting important bidirectional connections between anxiety and AUD (Anker & Kushner, 2019;Smith & Randall, 2012;Stewart et al., 2016). Anxiety disorders are consistently associated with self-reported use of alcohol to self-medicate or cope with their anxiety (Cooper et al., 2014;Morris et al., 2005). ...
... While these short-term effects may contribute to the perception that alcohol alleviates anxiety; evidence suggests that over the longer-term, social anxiety and alcohol use are mutually exacerbating because (a) alcohol can have neurobiological effects during intoxication and withdrawal that exacerbate anxiety symptoms (Koob et al., 2014); (b) relying on alcohol in social contexts prevent disconfirmation of unrealistic social fears, and erodes confidence to manage these situations unaided (Baillie & Sannibale, 2007;Tran & Haaga, 2002); and (c) increasing alcohol tolerance and consumption leads to increases in negative social outcomes, alcohol-related problems (e.g., work, relationship, legal or financial problems), and negative affect (e.g., embarrassment, shame, anxiety, low mood). In this way, a feed-forward cycle can emerge, whereby the experience or perception of alcohol as a mood enhancer reinforces alcohol consumption, which in turn increases negative affect and triggers further drinking (Anker & Kushner, 2019;Smith & Randall, 2012;Stewart et al., 2016). By developing an individualized formulation and functional analysis of a client's anxiety and alcohol, relevant treatment strategies can be identified to align with the specific cognitive, motivational, attentional, and behavioral processes that maintain and mutually exacerbate these disorders. ...
Chapter
Social anxiety disorder (SAD) and alcohol use disorder (AUD) are prevalent disorders that often co-occur. SAD onset typically precedes that of AUD, and co-occurrence of the two disorders is associated with greater symptom severity than either condition alone. This chapter reviews current evidence about psychological treatment of co-occurring SAD and AUD. While people with co-occurring SAD-AUD can benefit from single-disorder cognitive behavioral therapy (CBT) approaches (either AUD-focused or SAD-focused), treatment efficacy and long-term outcomes are negatively impacted by the co-occurring disorders. Two alternate treatment models have been tested for co-occurring SAD-AUD: (i) dual-focused treatment, and (ii) integrated treatment. In one of two trials, dual-focused CBT for SAD and AUD resulted in worse outcomes, potentially due to the demands of engaging in two separate treatments. By contrast, integrated SAD-AUD treatment involves a synthesized therapeutic protocol (delivered by one therapist) to address SAD, AUD and the inter-connection between these disorders. To date, two trials have found that integrated CBT for co-occurring SAD-AUD improved outcomes compared to AUD-focused treatment. The remainder of the chapter provides a comprehensive overview of the therapeutic strategies and clinical application of integrated CBT for co-occurring SAD and AUD. A clinical vignette illustrates the treatment, common challenges, and provides example worksheets and therapeutic dialogue.
... As a clinical psychology graduate student, studying under the mentorship of alcohol research expert, Robert Phil, I was interested in understanding mechanisms underlying the high comorbidity between panic disorder and alcohol use disorder (see review by Stewart et al., 2016). While developing my plans for my doctoral dissertation, I came across the AS construct and became fascinated with this individual difference variable as a potential common factor that might contribute to both panic and alcohol use disorders. ...
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Le présent article résume notre programme de recherche sur la sensibilité à l’anxiété (SA) – un facteur dispositionnel cognitif et affectif impliquant des craintes de sensations liées à l’anxiété en raison de croyances selon lesquelles ces sensations entraînent des conséquences catastrophiques. La SA et ses dimensions d’ordre inférieur sont considérées comme des facteurs transdiagnostiques de risque ou de maintien des troubles émotionnels et des troubles addictifs. La compréhension des mécanismes par lesquels la SA exerce ses effets peut révéler des cibles d’intervention clés pour les programmes de prévention et de traitement axés sur la SA. Dans le présent article, je passe en revue les recherches fondamentales que nous avons menées pour comprendre les mécanismes qui relient la SA à ces troubles et à leurs symptômes. Je décris également les interventions transdiagnostiques ciblées sur la SA et j’illustre la manière dont la recherche fondamentale a permis d’orienter le contenu de ces interventions. Enfin, je passe en revue les projets en cours dans mon laboratoire et je souligne les orientations futures importantes dans ce domaine. Bien que des progrès considérables aient été réalisés au cours des trois dernières décennies et que la recherche ait considérablement fait avancer notre compréhension de la SA en tant que facteur transdiagnostique, de nombreuses questions restent en suspens. Les réponses devraient nous aider à affiner les interventions afin d’en faire bénéficier au maximum les personnes qui ont une grande peur d’avoir peur.
... The two drinking outcomes were included given the overarching goal of the intervention. Coping motives was selected as an additional outcome, given that it is a malleable cognitive factor that has been shown to be linked with severe alcohol problems (Stewart et al., 2016). Quality of life was selected as the fourth outcome because it has been shown to be an important indicator of success in mental health treatments . ...
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Given prevalent alcohol misuse-emotional comorbidities among young adults, we developed an internet-based integrated treatment called Take Care of Me. Although the treatment had an impact on several secondary outcomes, effects were not observed for the primary outcome. Therefore, the goal of the current study was to examine heterogeneity in treatment responses. The initial RCT randomized participants to either a treatment or psychoeducational control condition. We conducted an exploratory latent class analysis to distinguish individuals based on pre-treatment risk and then used moderated regressions to examine differential treatment responses based on class membership. We found evidence for three distinct groups. Most participants fell in the “low severity” group (n = 123), followed by the “moderate severity” group (n = 57) who had a higher likelihood of endorsing a previous mental health diagnosis and treatment and higher symptom severity than the low group. The “high severity” group (n = 42) endorsed a family history of alcoholism, and the highest symptom severity and executive dysfunction. Moderated regressions revealed significant class differences in treatment responses. In the treatment condition, high severity (relative to low) participants reported higher alcohol consumption and hazardous drinking and lower quality of life at follow-up, whereas moderate severity (relative to low) individuals had lower alcohol consumption at follow-up, and lower hazardous drinking at end-of-treatment. No class differences were found for participants in the control group. Higher risk individuals in the treatment condition had poorer responses to the program. Tailoring interventions to severity may be important to examine in future research.
Article
Background: Previous research suggests that high anxiety sensitivity (AS) - a fear of arousal-related body sensations - may have implications not only for mental health symptoms but also for functional impairment. The aim of the present study was to examine whether elevated AS is associated with functional impairment by way of heightened anxiety symptoms and resultant depressive symptoms or unhealthy coping behaviours (i.e., alcohol use, exercise avoidance, sleep problems) in a chained mediation model. Method: Participants were 128 treatment-seeking individuals with high AS who qualified for an anxiety, depression, or posttraumatic stress disorder diagnosis. They completed self-report measures of AS, anxiety, depression, and unhealthy coping behaviours as part of a pre-treatment assessment battery for a larger study examining the efficacy of a cognitive behavioural intervention for AS. Data were analyzed using path analysis. Results: Results revealed a direct association between AS and functional impairment that was partially mediated through a chained indirect pathway from AS to anxiety symptoms to depression symptoms to functional impairment. Unhealthy coping behaviours did not serve as mediators. Limitations: Results are limited by the cross-sectional nature of the data. Conclusions: The present findings have clinical implications insofar as supporting the relevance of reducing AS and focusing on depressive symptoms when seeking to improve clients' functioning.
Chapter
Substance use is a common comorbidity for people experiencing anxiety-related disorders. Although exposure therapy has proven effective in both of these conditions, clinicians often report hesitations about applying these interventions when patients have substance-related comorbidities. There is now increasing evidence for treatment programs integrating substance use treatment and exposure therapy in a variety of areas, demonstrating the efficacy of applying these interventions in this population. The following chapter will describe the background knowledge and adjustments to treatment required to implement exposure interventions in this population.KeywordsExposureAnxietyTraumaPTSDAddictionSubstance useAlcoholDrugs
Article
The current investigation employed a cross-sectional design to evaluate the associations of COVID-19 stress, sleep disturbance, and substance use among a national sample of 143 adults (57.3% male, Mage = 38.5 years, SD = 11.28), surveyed at a single time-point using Amazon's MTurk platform. We hypothesized that COVID-19-related stress would be indirectly related to substance use outcomes (i.e. number of substance classes used daily, number of alcoholic drinks per occasion, substance use coping motives; but not substance use enhancement motives) through sleep disturbance severity. As expected, results indicated that the models examining indirect effects were statistically significant for number of substance classes used daily and substance use coping motives. However, there was no evidence that sleep disturbance explained the relation between COVID-19-related stress and number of alcoholic drinks per occasion or substance use enhancement motives. These findings underscore the importance of sleep disturbance in efforts to better understand how COVID-19-related stress is associated with certain types of substance use behavior.
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