Comorbidity Diagnoses and Treatment

The high rate of comorbid substance abuse and mental illness points to the need for a comprehensive approach that identifies, evaluates and simultaneously treats both disorders. Patients with co-occurring disorders often exhibit more severe symptoms than either disorder alone, underscoring the need for integrated treatment. Careful diagnosis and monitoring helps ensure that doctors do not mistake symptoms related to drug abuse, like intoxication and withdrawal, for a discrete mental disorder. Even in people whose comorbidities do not occur simultaneously, research shows that mental disorders can increase vulnerability to subsequent drug abuse and that drug abuse constitutes a risk factor for subsequent mental disorders. Therefore, diagnosis and treatment of one disorder will likely reduce risk for the other or at least improve its prognosis. Many researchers strongly support the need to develop effective interventions to treat both conditions concurrently, but treatment has been difficult to implement in practice because the health care systems in place to treat substance abuse and mental illness are disjointed and inefficient. Physicians tend to treat patients with mental illnesses, whereas a mix of providers with varying backgrounds delivers drug abuse treatment. Some substance abuse treatment centers do not administer any medications, including those necessary to treat patients with severe mental disorders. Behavioral treatment options that doctors customize for a given age group or gender show promise for treating drug abuse and mental disorder comorbidities. Research is under way to identify medications that target both types of disorders. Clinicians and researchers generally agree that broad spectrum diagnosis and concurrent therapies, both pharmacological and behavioral, will lead to better outcomes for patients with comorbid disorders. The stigma attached to substance abuse and mental disorders often hinders early diagnosis and proper treatment. Greater understanding resulting from recent scientific findings that substance abuse and mental illness disrupt some of the same brain functions will reduce the social stigma that hinders treatment seeking, quality and access by patients with either or both conditions.

Short Term Residential Treatment

Short term residential programs provide intensive and brief treatment based on a modified 12-step approach. Originally, addiction specialists designed these programs to treat alcoholics with addiction problems, but during the cocaine epidemic of the mid 1980s, many residential treatment programs began to address other types of substance abuse disorders. The original residential treatment model consisted of a three to six week hospital stay for inpatient treatment, followed by extended outpatient therapy and participation in a self help group, such as Alcoholics Anonymous. Following stays in residential treatment programs, individuals should remain engaged in outpatient treatment programs and or aftercare programs. These programs help to reduce the risk of relapse once a patient leaves the residential setting.

Gambling is the wagering of money or something of material value as the stakes on an event with an uncertain outcome with the primary intent of winning additional money and or material goods. Typically, the outcome of the wager is evident within a short period. Gaming refers to instances in which the law permits the type of gambling. Gaming and gambling are not mutually exclusive. A gaming company offers legal gambling activities to the public and a gaming control board may regulate the gaming company, like the Nevada Gaming Control Board. However, the English-speaking world does not acknowledge this distinction often. For instance, in the UK, the regulator of gambling activities is called the Gambling Commission not the Gaming Commission. In addition, the word gaming describes activities that do not involve wagering, especially online. Gambling is also a major international commercial activity, with the legal gambling market totaling an estimated $335 billion in 2009. Under United States federal law, gambling is legal in the country and states are free to regulate or prohibit the practice. Gambling has been legal in Nevada since 1931, forming the backbone of the economy of the state. The city of Las Vegas is perhaps the best known gambling destination in the world. In 1976, gambling became legal in Atlantic City, New Jersey and in 1990, under state law, gambling became permissible in Tunica, Mississippi; both of those cities have developed extensive casino and resort areas since then. Since a favorable United State Supreme Court decision in 1987, many American Indian tribes have built their own casinos on tribal lands as a way to provide revenue for the tribe. Because the tribes are sovereign nations, they are often exempt from state laws that restrict gambling and are instead regulated under federal law.

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When the Stakes Turn Toxic

Anyone who’s bought a lottery ticket or played bingo has gambled. Gambling is any game of chance in which money changes hands. It’s common in most cultures around the world. Many people enjoy gambling as recreation without causing harm to themselves or others. Yet some people can’t control their impulse to gamble, even when it takes a terrible toll on their lives.         

For these gamblers and their families, researchers have been making progress in several areas. Scientists are learning why people have problems with gambling: how common it is, what goes on inside the gambler’s brain, which is at risk and what kinds of treatment can help.

Problem gambling is defined by some researchers as gambling that causes harm to the gambler or someone else, in spite of a desire to stop. Between 2% and 4% of Americans struggle with this condition. Problem gambling can progress to a recognized psychiatric diagnosis called pathological gambling.

Pathological gambling may affect from 0.4% to 2% of Americans. “Pathological gambling comes with a constellation of problems that contribute to chaos,” says Dr. Donald Black of the University of Iowa. “It’s associated with worse physical health, excessive smoking, excessive drinking, not exercising, not seeing primary care doctors and worse dental care. It also fuels depression, family dysfunction, crime, bankruptcy and suicide.”

Together, pathological and problem gambling may affect up to 5% of Americans. That number may rise, though. Laws in many states are creating more options for legal gambling, and internet gambling is becoming more common.

Still, gambling is often done in family settings, condoned or encouraged by parents. And the younger you start, the more likely you are to get into trouble later on. From 3% to 8% of adolescents have a problem with gambling.

Dr. John Welte of the University of Buffalo has found that, across the lifespan, gambling problems are even more common than alcohol dependence. They are also much more common in males, in young people, and in people who live in relatively poor neighborhoods. “That’s not true of the prevalence of alcoholism,” says Welte. “Alcoholism is much more democratic. So think about motives for gambling. People are hoping that winning will improve their lot. That makes them more vulnerable to developing a gambling problem.”

In a study of mostly African-American inner-city youth, Dr. Silvia Martins of Johns Hopkins University has found that about 15% have some form of problem gambling. Most at-risk were adolescents and young adults who began showing symptoms of depression at age 12. They were highly impulsive, although not hyperactive or aggressive. As the African-American boys developed into their teens and early adulthood, gambling appeared to be a separate risk factor for early fatherhood and criminal arrest.

“We are following up with these inner-city kids every single year as they enter adulthood,” says Martins.

But why is gambling irresistible to some folks and not others? Using advanced imaging techniques, Dr. Alexander Neumeister of Mount Sinai School of Medicine looked at the brains of people with gambling problems and alcohol problems. He measured the number of special receptors involved in regulating impulse control and other factors.          

“A key feature of addiction is impaired impulse control,” says Neumeister. “Abnormal function of the forebrain leads to reduced tolerance to waiting.” The resulting impatience may cause people to act without considering the consequences. “Our imaging clearly points toward the importance of impaired forebrain function in addiction.”

Pinpointing areas in the brain’s reward center, Neumeister’s team found that people with alcohol addiction and gambling problems show different functioning of these special receptors compared to healthy people. The differences were related to the severity of addiction. Other researchers are trying to develop drugs that could treat the affected areas.

Talk therapy can also help. Dr. Nancy Petry at the University of Connecticut Health Center works with pathological gamblers and people seeking treatment for drug use disorders. Gambling problems arise in about 10% to 20% of substance abusers. Petry compared the use of different types of talk therapy, including very brief interventions and cognitive-behavioral therapy CBT. CBT teaches people how to think differently about problems and then act on that knowledge.

“We found very brief interventions and CBT were effective in reducing gambling and gambling-related problems,” Petry says. “There was a significant improvement relative to usual care or standard forms of treatment like Gamblers Anonymous [a 12-step program].”

Anybody can have a gambling problem, and no one should feel ashamed or be afraid to seek treatment. “Pathological gambling is a medical disorder, not a sin or a vice,” says Dr. Carlos Blanco of Columbia University and the New York State Psychiatric Institute. “There is no stereotype. The main predictor of outcome is really motivation.”

In other words, what counts most is a strong drive or desire to take action. Blanco offers gamblers motivational interviewing, which helps them explore their mixed feelings about trying to quit gambling. This primes them to be ready and willing to begin CBT. Using both therapies together can be very effective.

If you have concerns about your gambling, ask for help. Your health provider can work with you to find the treatment that’s best for you.